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INDIAN JOURNAL OF PUBLIC HEALTH
(Quarterly Journal of Indian Public Health Association)
Indian Journal of Public Health is published quarterly by Indian
Public Health Association.
Manuscripts and correspondence should be addresed to : Managing
Editor, Indian Journal of Public Health, 110 Chittaranjan Avenue
(3rd floor), Kolkata-700073, West Bengal.
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Editorial Office:
110, Chittaranjan Avenue, Kolkata - 700 073
Phone : 32913895 (033)
E-mail: ijph2005@yahoo.com / ijph@iphaonline.org
Editorial Board
Chief Editor
Dr. V. K. Srivastava
Editor
Dr. Samir Dasgupta
Associate Editor
Dr. R. N. Chaudhuri
Dr. Sanjay Chaturvedi
Joint Editor
Dr. D. K. Raut
Dr. A. B. Biswas
Assistant Editor
Dr. Kaushik Mishra
Dr. Prabir Kumar Sen
Managing Editor
Dr. Dilip Kumar Das
Assistant Managing Editor
Dr. Rabindra Nath Sinha
Members
Dr. D.H. Ashwath Narayana
Dr. (Lt.Col.) Atul Kotwal
Dr. B. M. Vashisht
Dr. N. K. Goel
Dr. Prasant Kr. Saboth
Dr. D. M. Satpathy
Dr. Chitra Chatterjee
Dr. Rabindra Nath Roy
Dr. Ashok Kr. Mallick
Dr. Kunal Kanti Majumdar
Secretary General (Ex-officio)
Dr. (Mrs.) Madhumita Dobe
Vol. 52 No.3 July - September 2008
Journal Advisory Committee
Dr. Deoki Nandan
Dr. Sandip Kumar Ray
Dr. Ranadeb Biswas
Dr. F. U. Ahmed
Dr. J. Ravi Kumar
Mrs. Shuva Kumari
Indian Journal of Public Health
Vol.52 No.3 July - September 2008
Contents
Editorial
Injury: the most Underappreciated and Unattended Pandemic 115
Sanjay Chaturvedi
Original Article
Prevalence of Risk Factors for Non-Communicable Disease
in a Rural Area of Faridabad District of Haryana 117
A. Krishnan, B. Shah, Vivek Lal, D. K. Shukla, Eldho Paul, S. K. Kapoor
Epidemiology of Disability in a Rural Community of Karnataka 125
K. S. Ganesh, A. Das, J. S. Shashi
Elimination of Iodine Deficiency Disorders – Current Status in
Purba Medinipur District of West Bengal, India 130
A. B. Biswas, I. Chakraborty, D. K. Das, A. Chakraborty, D. Ray, K. Mitra
Special Article
Integrated Diseases Surveillance Project (IDSP) Through a Consultant’s Lens 136
K. Suresh
Short Communication
Hypertension and Epidemiological Factors among Tribal Labour
Population in Gujarat 144
Rajnarayan R Tiwari
Respiratory Morbidity among Street Sweepers Working at Hanumannagar
Zone of Nagpur Municipal Corporation, Maharashtra 147
Sabde Yogesh D, Sanjay P Zodpey
Needle Sticks Injury among Nurses Involved in Patient Care: A study in
Two Medical College Hospitals of West Bengal 150
G. K. Joardar, C. Chatterjee, S.K.Sadhukhan, M.Chakraborty, P. Das, A.Mandal
Dietary Profile of Sportswomen Participating in Team Games at
State/National Level 153
Ritu Jain, S. Puri, N. Saini
Perception Regarding Quality of Services in Urban ICDS Blocks in Delhi 156
A. Davey, S. Davey, U. Datta
A Study on Delivery and Newborn Care Practices in a Rural Block
of West Bengal 159
P. Das, S. Ghosh, M. Ghosh, A. Mandal
Hospitalisation due to Infectious and Parasitic Diseases in
District Civil Hospital, Belgaum, Karnataka 161
A. C. Naik, S. Bhat, S. D. Kholkute
Review Article
Homelessness: A Hidden Public Health Problem 164
S. Patra, K. Anand
Letter to the Editor:
HIV/ AIDS Awareness through Mass Media – the Measurement of Efforts
Made in an Urban Area of India 171
Hem Chandra, K. Jamaluddin, L. Masih, K. Faiyaz, N. Agarwal, D. Kumar
Undernutrition in 5-10 Year Olds: Experiences from a PHC in Pondicherry 172
S. Sarkar, S. Ananthakrishnan
115
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Editorial
Injury: the most Underappreciated and Unattended Pandemic
Injury accounts for 9% of global mortality and
12% of the global burden of disease in terms of
disability adjusted life years (DALY) lost. They figure
in the leading causes of death throughout the world
and yet remain the most underappreciated pandemic.
Every year, an estimated 5 million people die from
injury1. Road traffic injury (RTI) alone accounts for
25% of mortality and 22% of DALY lost. Ranked 9th
in terms of worldwide burden, they are projected to
ascend to 3rd rank by 20202. In many parts of the
world, injury related database is thin and the real load
may be heavier than the estimates. For every injury
related mortality, several thousand more require
hospital treatment and suffer with impairments,
frequently with disabling consequences. Injury affects
the productive work force, youth and school-going
children the most. It follows the inverted U-shaped
curve with age. Almost 50% of injury related mortality
is borne by 15-44 years age group. Under-five children
account for 25% of drowning deaths and over 15% of
fire-related deaths. Males bear the major brunt in all
ages, gender difference being the highest in 15-44 years
age group. Mortality from RTI and interpersonal
violence is about 3 times higher among males than
that in females. Reducing the burden of injury is going
to be one of the main challenges for public health in
this century. In terms of cost, RTI alone accounts for
1-2% of the gross national product to most of the
countries. For the low and middle-income countries
(LMICs), this exceeds the total developmental aid
received by them. Assessment of direct and indirect
costs of injury involves complex methods that are
seldom free of limitations and compromises. What
generates a great deal of discussion is the economic
quantization of human life. Putting monetary values
on pain, suffering and death is ethically unacceptable
to many.
The burden of injury related mortality and
morbidity is comparatively very high in low and middle-
income countries (LMICs). Over 90% of this burden is
borne by such countries. Recent evidence suggests that
victims of life-threatening but salvageable injury have
six times higher probability of death in a low-income
setting3. South-East Asia (SEA) alone bears 31% of
the world’s burden of injury and 27% of injury related
mortality. Thousands of children saved from infectious
and nutritional diseases are killed or crippled by injury
in this region. RTI is the biggest culprit in most of these
countries - total regional share in the global burden of
RTI being 34%4. It is also estimated that SEA region
accounts for 57% of the global burden of burn injury
and 53% of burn mortality1. In Bangladesh and
Maldives, drowning is the commonest cause of
accidental deaths. India specific information base on
injury is also very weak and the published data is hard
to come by. The latest published review on RTI in India
has estimated 2-5 million hospitalizations and over
100,000 deaths in 2005. RTI alone accounts for 10-
30% of all hospitalizations, being highest in the state
of Tamilnadu and lowest in Nagaland5.
If we take a stock of our response to this ongoing
pandemic, the situation looks scary. Let us start with
info-capture and surveillance. In the absence of a
trauma registry system, the injury related information
is not uniformly or systematically captured, analysed
or disseminated in several South Asian countries,
including India. Even in the tertiary care facilities –
where there are functioning medical record divisions –
the distal recording units, like emergency rooms, are
unable to optimally utilise the provisions provided in
Chapters XIX & XX of ICD-106 for coding and
classification of injury. Several circumstantial attributes,
which are essential for subsequent coding and
classification, are not optimally captured in the distal
recording units. Besides the 3 character alpha-numeric
core code, which is mandatory for any international
reporting, Chapter XX – a newer feature of ICD 10,
provides an additional ‘e-code’ for all cases of injury7.
This code is about the external cause of injury, and is
a significant information for injury surveillance. No
proximal data management facility can generate this
e-code once the required information is lost at the distal
capture unit. This is a huge gap in the injury surveillance
process, right at the data-generation level. The initial
step in this direction would be to develop sentinel units
for injury surveillance in most of the tertiary and
116
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
secondary care hospitals – before going for the goal of
establishing the ‘National Trauma Registry of India’.
Certain short term activities can be identified and
operationalized, e.g.: framing the case definitions;
development of data collection tool; development of
data capture process, protocol, and infrastructure; and
identification and training of stakeholders. The long
term activities would constitute: quality assurance
mechanisms; evaluation; knowledge transfer and
collaboration.
The next or parallel step should be to initiate and
sustain a population-based programme on injury
prevention. Advocacy starts with identification of
stakeholders. A felt need for such a programme is to
be created so that the programme gains widest possible
acceptance and support. The conceptual framework
of a ‘National Injury Prevention Programme’ must be
inclusive in character to accommodate all the significant
actors and agencies. This collaborative network should
be most visible at the district and sub-district levels.
Governments which improve the organization of injury
prevention services benefit from reduced injury related
burden, as compared to similarly resourced
governments which do not. With improved and
systematic response towards injury prevention, the
range of reduction in the mortality alone will bear
incremental rewards. Benefit in terms of DALY saved
will go manifold. Such a national response to the
problem of injury is yet to materialize in many
developing countries. The rationale to initiate a
population-based national programme on injury
prevention is quite strong and visible. It just needs to
be effectively advocated.
References:
1. WHO. The injury chart book: a graphical
overview of the global burden of injuries. Geneva:
WHO; 2002.
2. WHO. World report on road traffic injury
prevention. Geneva: WHO; 2004.
3. Rivara FP, Mock C. The 1,000,000 lives campaign
(editorial). Inj Prev. 2005;11:321-3.
4. WHO-SEARO. Strategic plan for injury prevention
and control in South-East Asia. New Delhi:
WHO-SEARO; 2002.
5. Gururaj G. Road traffic deaths, injuries and
disabilities in India: current scenario. Natl Med J
India 2008;21:14–20.
6. WHO. International statistical classification of
diseases and related health problems – tenth
revision (ICD-10). vol. 1. Geneva: WHO; 1992.
7. WHO. Foundations and fundamentals of injury
prevention and control, and safety promotion
(section 1, lesson 1). In: TEACH VIP [CD-ROM].
Geneva: WHO; 2005.
Sanjay Chaturvedi
Associate Editor, IJPH &
Professor of Community Medicine,
University College of Medical Sciences and GTB
Hospital, Delhi
E-mail: cvsanjay@hotmail.com
Editorial: Injury: the most Underappreciated and Unattended Pandemic
117
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Introduction
Non- communicable diseases (NCDs) contributed
60% of deaths and 43% of global burden of disease in
the year 2002, and by 2020, are projected to account
for 73% of deaths and 60% of disease burden1. Clearly,
NCDs can no longer be regarded as a problem confined
to the developed countries and urban society.
Affluence, progressive ageing of population, improving
socio-economic conditions and changed life styles have
caused an increase in non-communicable diseases and
these are spreading to rural areas as well and these
need to be documented to dispel myths that NCDs
Original article
Prevalence of Risk Factors for Non-Communicable Disease
in a Rural Area of Faridabad District of Haryana
*A. Krishnan1, B. Shah2, Vivek Lal3, D. K. Shukla4, Eldho Paul5, S. K. Kapoor6
1Associate Professor, Centre for Community Medicine, AIIMS, New Delhi; 2Senior Deputy Director General (NCDs),
Division of Non Communicable Diseases, ICMR, New Delhi; 3Junior Resident, Centre for Community Medicine, AIIMS;
4Deputy Director General, Division of Non Communicable Diseases, ICMR; 5Statistical Assistant, Centre for community
medicine, AIIMS; 6Professor Emeritus, Community Health Departt, St Stephens Hospital, Delhi.
*Corresponding author: kanandiyer@yahoo.com
are a problem only in urban areas.
Together NCDs (cardio-vascular diseases, cancer,
chronic obstructive pulmonary diseases and diabetes)
accounted for 42.7% of deaths in 2000 in India2. These
are linked by common risk factors related to lifestyle
like tobacco use, unhealthy diet, physical inactivity,
obesity, high blood pressure, raised cholesterol and
glucose levels. These risk factors are measurable and
largely modifiable and thus continuing surveillance of
the levels and patterns of risk factors is of fundamental
importance to planning and evaluating preventive
activities in the control of NCDs.
Abstract
Background & Objectives: To estimate the prevalence and levels of common risk factors for non-
communicable disease in a rural population of Haryana. Methods: The study involved a survey
of 1359 male and 1469 female respondents, aged 15-64 years. Multistage sampling was used for
recruitment (PHCs/ sub-centres/ villages). All households in the selected villages were covered,
with one male and one female interviewed in alternate household. WHO STEP- wise tool was
used as the study instrument which included behavioural risk factor questionnaire and physical
measurements of height, weight, waist circumference and blood pressure. The age adjusting
was done using rural Faridabad data from Census 2001. Results: The age adjusted prevalence of
daily smoked tobacco was 41% for men and 13% for women. Daily smokeless tobacco use was
7.1% and 1.2% for men and women respectively. The prevalence of current alcohol consumption
was 24.6% among men and none of the women reported consuming alcohol. The mean number
of servings of fruits and vegetables per day was 3.7 for men and 2.7 for women. The percentage
of people undertaking at least 150 minutes of physical activity in a week was 77.8% for men and
54.5% for women. Among men 9.0 % had BMI > 25.0 compared to 15.2% among women. The
prevalence of measured hypertension, i.e. >140 SBP and/or >90 DBP or on antihypertensive
drugs was 10.7% among men and 7.9% among women. Conclusion: The study showed a high
burden of tobacco use and alcohol use among men, inactivity and overweight among women
and low fruit and vegetable consumption among both sexes in rural areas.
Key words : Alcohol, BMI, Hypertension, Physical inactivity, Risk factors, Rural, Tobacco.
118
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
An integrated approach to risk factor surveillance
is vital for NCD control. Surveillance of NCD risk
factors as currently practiced in India has largely
focused on separate risk factors like tobacco, alcohol
or diet. Very few studies have been undertaken to
assess physical activity. There is a felt need to have a
comprehensive look at the NCD risk factors using
standard methodology to ensure comparability. Such
tools have recently been developed by WHO and are
being used by health planners to generate evidence
for advocacy.
Comprehensive Rural Health Services Project
(CRHSP), Ballabgarh run by All India Institute of
Medical Sciences (AIIMS) was among the sites where
it was pilot tested and later became a part of the
multicentric surveillance site coordinated by Indian
Council of Medical Research (ICMR). As part of this
we studied a rural population of Haryana for
prevalence of common risk factors of NCDs using WHO
STEPS approach. We report the results of this survey
here.
Material and methods
We conducted a survey in the rural area of
Ballabgarh, in Faridabad district of Haryana from April
2003 to January 2004. A total of 2500 participants
were aimed at, with 250 in each age (15-24, 25-34,
35-44, 45-54 and 55-64) and sex group. Multistage
sampling was used for the purpose of recruitment. Two
PHCs were selected randomly from among a total of
5 PHCs in the block. Thereafter, one sub-center in each
PHC was selected randomly. One village was randomly
selected from the list of villages in the sub-center. If
the village was small, an additional village was selected
from the same sub-center. All the households in the
selected villages were covered, with one male and one
female being interviewed in alternate households. The
selection of the male/female was from the list of eligible
in that house and was done in a random manner. If
need be, the household was revisited a second time at
least one of which was on a different day/time.
The WHO STEP-wise tool was used and the
behavioural risk factor Questionnaire was suitably
modified and translated in local language. It included
questions on socio-demographic status, data on
tobacco and alcohol use, measures of dietary habits
and physical inactivity. Standard procedure was
followed as per STEPs protocol for anthropometric and
blood pressure measurements. The height was
measured using adult portable stadiometer to the
nearest 0.1 cm. SECA digital weighing scales were used
to measure weight of the individuals and was recorded
in kilograms up to 0.1 kg. A SECA constant tension
tape was used to measure Waist circumference to the
nearest 0.1 cm. The blood pressure was measured using
OMRON digital automatic blood pressure monitor. All
measurements were done at domiciliary level. Three
male and three female workers were trained by a team
of ICMR and were regularly supervised by the
investigators and ICMR team.
Definitions: (Source- WHO STEPS manual3)
Current daily smokers were defined as those who
were currently smoking cigarettes, bidis or
hookah daily.
Current daily smokeless tobacco users were
defined as those who were currently using
chewable tobacco products, gutka, naswar, khaini
or zarda paan daily.
Current alcohol drinkers were defined as those
who reported to consuming alcohol within the
past one year.
One standard drink was equivalent to consuming
one standard bottle of regular beer (285 ml), one
single measure of spirits (30 ml) or one medium
size glass of wine (120 ml).
One serving of vegetable was considered to be 1
cup of raw green leafy vegetables, ½ cup of other
vegetables (cooked or chopped raw) or ½ cup of
vegetable juice.
One serving of fruit was considered to be 1
medium size piece of apple, banana or orange,
½ cup of chopped, cooked, canned fruit or ½
cup of fruit juice, not artificially flavoured.
Physical inactivity was defined as less than 10
minutes of activity at a stretch, during leisure, work
or transport.
Body mass index (BMI) was calculated by dividing
the weight (in kilograms) by square of height (in
meters). Overweight was defined as BMI ³ 25 and
< 30
Obesity was defined as BMI ≥ 30
Hypertension was defined as BP ≥ 140/≥ 90 or
currently on antihypertensive drugs.
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
119
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Ethical clearance for the study was obtained from
AIIMS. Written informed consent was obtained from
each participant. The results of the measurement were
provided to the respondents and all case needing
referral were referred to the Civil Hospital at Ballabgarh
to consult a physician. Data were entered
simultaneously. An independent data entry operator
did the reentry of 10 percent data and these were
validated. The data was analyzed using SPSS for
windows (version 10.0). The age standardized
percentages for the target age group were computed
using rural Faridabad data from Census 2001.
Results
A total of 1359 men and 1469 women were
included in the survey. Among the men, majority were
unskilled or landless labourers (23.95%). Of the
women, 96% were housewives. About 38% of the men
had studied up to high school, as against 11.1% who
had never been to school. Majority of women had
never attended school (56.6%), while only 10% had
studied beyond 8th standard.
Tobacco & alcohol use (Table 1)
The age-adjusted prevalence of daily smoked and
smokeless tobacco use in men was 41.0% and 7.1%
respectively. The same for women was 13.0% and
1.2% respectively. For men, smoked tobacco use was
highest in 45-54 years age group, whereas smokeless
tobacco in the forms of khaini, gutka, snuff and chewed
tobacco was most prevalent in 25-34 years age group.
There was a steep rise in daily smoking of tobacco
after 24 years of age from 9.4% in 15- 24 years age
group to 46.6% in 25- 34 years age group. Thereafter
there was a gradual rise to a peak of 72.2% at 45-54
years age group. The prevalence then showed a decline
in the later age group. For women both smoked and
smokeless tobacco use was more common in the older
age group of 55-64 years. The median age for starting
to smoke among men was 20.0 yrs (IQR 17.0-25.0),
while the median duration of smoking was 20.0 yrs
(IQR 10.0-29.4). The median age for starting to smoke
among women was 31.0 yrs (IQR 25.0-40.0), while
the median duration of smoking was 12.9 yrs (IQR
5.0-22.0). Smoking tobacco in the form of bidis was
the most common with the mean number of bidis
smoked per day among men being 6.1 and among
women being 0.7. Khaini was the commonest form in
which smokeless tobacco was consumed, among both
men and women.
None of the women reported consuming alcohol.
The prevalence of ever alcohol consumption among
men was 29.0% and that of current alcohol
consumption was 24.6%. The difference between the
two was maximum at the age of 55-64 years. The
prevalence was highest in the 35-44 years age group.
The current alcohol consumers comprised 84.8% of
Table 1. Prevalence of tobacco use and alcohol use by age & sex
Age in years Men Women Men*
Daily Daily Daily Daily Ever Current
smoked smokeless smoked smokeless alcohol alcohol
tobacco use tobacco use tobacco use tobacco use consumption consumption
(n=1359) (n=1359) (n=1469) (n=1469) (n=1359) (n=1359)
15-24 9.4% 6.5% 0.4% 0.4% 10.0% 9.4%
25-34 46.6% 10.1% 7.3% 0.2% 32.8% 29.7%
35-44 63.8% 6.8% 18.2% 1.7% 47.5% 41.5%
45-54 72.2% 4.9% 34.5% 1.8% 44.1% 34.8%
55-64 67.4% 4.3% 38.7% 4.9% 36.2% 20.2%
Age adjusted 41.0% 7.1% 13.0% 1.2% 29.0% 24.6%
prevalence** (38.4-43.7) (5.8-8.6) (11.3-14.8) (0.6-1.8) (26.5-31.4) (22.3-27.0)
* None of the women reported alcohol consumption, **95% Cl values in parenthesis
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
120
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
those who had ever consumed alcohol. The mean
number of drinks consumed in the past 7 days was
12.0 (95% CI 9.2- 14.9). This was highest in the age
group 45- 54 yrs. A total of 4.6% men consumed, more
than or equal to 5 drinks on any day, in the last week.
Men were consuming more fruits and vegetables
than women in any age group. The mean number of
servings of fruits and vegetables per day was 3.7
(95%CI 3.6-3.8) for men and for women, it was 2.7
(95% CI 2.6-2.8). The proportion of men consuming
>5 servings of fruits and vegetables per day was 6.6%,
while only 1.8% women reported to consuming this
much amount. Across the age groups, mean number
of servings of fruits and vegetables consumed per day
were similar. The mean number of days in a week when
fruits were consumed was 2.05 (95% CI 1.93-2.16)
for men and for women was 1.46 (95% CI 1.36-1.56).
Physical inactivity (Table 2)
The physical inactivity was highest during leisure
time and was least during transport from one place to
another for both men and women. The percentage of
people undertaking at least 150 minutes of physical
activity in a week was lesser for women (54.5%) than
for men (77.8%) among all age groups. Such level of
physical activity was highest in the age group 35-44
years (81.9% and 72.9% for men and women
respectively) and lowest in 55-64 years age group
(70.2% and 37.9% for men and women respectively).
The mean duration of physical activity in minutes for
all male subjects for a week was 1103.6 (95%CI
1068.5-1192.7) and 781.4 (95%CI 730.9-832.0) for
all women. This was more in the age group 35-44 years
for both men and women.
Table 2. Pattern of physical inactivity by domains
Age in years Men Women
Leisure Work Transport Leisure Work Transport
(n=1359) (n=1359) (n=1359) (n=1469) (n=1469) (n=1469)
15-24 79.2% 71.4% 15.5% 95.4% 74.1% 54.9%
25-34 89.7% 50.9% 21.0% 99.5% 55.5% 41.1%
35-44 87.5% 43.8% 20.0% 97.3% 39.7% 30.6%
45-54 87.0% 49.1% 19.3% 97.0% 57.1% 41.1%
55-64 90.4% 58.5% 23.2% 98.4% 71.8% 67.5%
Age adjusted 85.2% 57.2% 18.8% 97.3% 59.9% 45.7%
Total (95% Cl) (83.1-86.9) (54.4-59.8) (16.7-20.9) (96.3-98.0) (57.4-62.4) (43.1-48.2)
Table 3. Distribution BMI & waist circumference by age & sex
Age in years Men (n=1359) Women (n=1362)
Mean BMI Mean waist Mean BMI Mean waist
(95%CI) circumference (95%CI) circumference
(95%CI) (95%CI)
15-24 19.7(19.4-20.0) 72.2(71.5-72.9) 19.6(19.3-19.8) 68.7(68.0-69.4)
25-34 20.7(20.4-21.0) 77.8(76.9-78.8) 20.3(20.0-20.7) 71.9(71.0-72.9)
35-44 21.0(20.6-21.4) 81.5(80.2-82.7) 22.0(21.5-22.5) 77.4(76.0-78.7)
45-54 21.0(20.5-21.6) 82.6(80.9-84.3) 22.9(22.2-23.6) 81.1(79.2-83.0)
55-64 20.7(19.9-21.5) 82.3(79.9-84.7) 22.421.5-23.3) 83.4(81.2-85.7)
Age adjusted
mean 20.4(20.2-20.6) 77.4(76.9-77.9) 21.0(20.7-21.2) 74.3(73.7-74.9)
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Anthropometry (Table 3 & 4)
A total of 107 women were found to be pregnant
and these were excluded for anthropometric
examinations. Both mean BMI and waist circumference
was highest in 45-54 years age group for men. For
women, the mean waist circumference was highest in
55-64 years, while mean BMI was highest in 45-54
years age group. There was an increase in BMI among
women as compared to men after 25-34 years of age
group and thereafter for all age groups; obesity was
more common in women. Across all age groups
overweight was more common among women than
men. The prevalence of underweight was similar for
both men and women. After 35 years of age overweight
and obesity combined was more than thinness among
women while thinness was consistently more prevalent
than overweight and obesity combined, for all age
Table 4 . Prevalence of thinness, overweight and obesity in the study subjects
Age Group Male (n=1359) Female (n=1362)
BMI<18.5 BMI BMI BMI BMI<18.5 BMI BMI BM
18.5-24.9 ≥25.0—<30.0 ≥30 18.5-24.9 ≥25.0—<30.0 ≥30.0
(%) (%) (%) (%) (%) (%) (%) (%)
15-24 36.3 59.8 2.9 1.0 37.2 57.5 5.3 0
25-34 21.9 69.5 7.5 1.2 32.8 56.3% 9.7% 1.2%
35-44 25.8 61.3 10.6 2.3 22.2 54.7% 17.9% 5.2%
45-54 25.6 59.5 13.0 1.9 16.8 52.7% 21.6% 9.0%
55-64 33.0 51.0 13.8 2.1 24.2 48.4 19.4 8.1
Age adjusted 29.1 61.9 7.5 1.5 29.1 55.8 12.1 3.1
prevalence* (26.0-30.9) (59.6-64.8) (6.1-9.0) (1.1-2.6) (26.2-31.3) (52.9-58.3) (10.7-14.2) (2.4-4.3)
* 95% Cl values in parenthesis
Table 5. Distribution of mean systolic & diastolic BP & % hypertensive by age & sex
Age in years Men Women
Mean systolic Mean diastolic % Hypertensive Mean systolic Mean diastolic % Hypertensive
BP BP (≥140/≥90 or on BP BP (≥140/≥90 or on
(95% CI) (95% CI) antihypertensive) (95% CI) (95% CI) antihypertensive)
15-24 120.6 70.4 4.9 110.2 66.4 1.5
(119.6-121.6) (69.7-71.2) (109.2-111.2) (65.6-67.1)
25-34 118.5 72.8 7.1 109.0 68.4 2.9
(117.2-119.7) (71.8-73.8) (107.8-110.1) (67.4-69.4)
35-44 118.5 75.6 12.6 111.9 71.4 7.3
(116.7-120.4) (74.4-76.9) (110.3-113.6) (70.2-72.6)
45-54 123.0 78.1 21.9 121.6 75.5 22.4
(120.4-125.5) (76.3-79.8) (118.6-124.6) (73.7-77.3)
55-64 127.0 76.2 30.1 131.2 76.1 30.9
(122.4-131.6) (73.7-78.8) (127.3-135.1) (74.2-78.0)
Age
adjusted 120.4 73.4 10.7 113.3 69.8 7.9
mean (119.6-121.1) (72.8-73.9) (9.0-12.4) (112.5-114.1) (69.3-70.3) (6.6-9.4)
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
122
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
groups among men. A total of 2.2% of men had waist
circumference ≥ 102 cm, which was most commonly
seen in the 55-64 years age. This was against the cut-
off for women of ≥ 88 cm which was seen in 13.2%.
Again it was more common in the 54-65 years age
group.
Blood pressure (Table 5)
The prevalence of self- reported hypertension was
3.5% in men and 6.8% in women, whereas the
prevalence of hypertension (defined as BP ≥ 140/90
or currently on antihypertensive drugs) was 10.7% in
men and 7.9% in women. The mean systolic and
diastolic blood pressure among men was 120.4 mmHg
and 73.4 mmHg respectively. The same among women
were 113.3 mmHg and 69.8 mmHg respectively. There
was a sharp increase in prevalence of hypertension
among women after 35-44 years age group. The huge
male and female difference in younger age groups
disappeared post menopause. The prevalence of self-
reported diabetes was 0.7% among men and 0.5%
among women and showed an increasing trend with
age.
Discussion
Our study presents the burden of major NCD risk
factors, in a rural area, using WHO STEPS approach.
This is among the first sites to use this comprehensive
approach to measure the NCD risk factor burden. It
was not the purpose of this survey to compare this
burden with other risk factor specific surveys done by
different people at different places at different times
etc. However, some limited comparison from other
surveys would be meaningful to get an insight into the
burden at national level.
Tobacco use in India is high and there are
considerable differences in the types and methods by
which it is used. A prevalence of 41% of daily smokers
among men was similar to that reported by NFHS 2
for Haryana (40.6%)5, but in women our finding of
13% is much higher than that of NFHS 2 (3.6%). The
prevalence of ever smokers in NFHS 2 was 42.4% and
3.8% for men and women respectively. A survey of
tobacco use in Karnataka and Uttar Pradesh (UP)
found the prevalence of ever smoking in Karnataka to
be 33.1% among rural men and 0.6% among rural
women4. The prevalence of current smoking was
31.2% and 0.6% among rural men and women
respectively. In UP, the prevalence of ever smoking
was 28.3% among rural men and 2.9% among women.
Current smoking showed a prevalence of 28.2% and
2.8% among men and women respectively. Similar to
our study, others have also found that khaini and bidis
to be the commonest form of tobacco use 4-6. The
difference between ever use and current use was small,
suggesting that tobacco use once initiated, is continued
and quitting of tobacco use is infrequent.
The steep rise in alcohol consumption from 9.4%
in 15-24 years age group to 29.7% in 25-34 years age
group could be due to the economic independence
gained during this time in life. The consumption rose
to a peak of 41.5% in 35-44 years age group, and
gradually declined thereafter. Most of the men who
reported to having consumed alcohol ever in life, had
also done so in the last one year indicating that few
people quit alcohol. Our prevalence rates were similar
to that of NFHS 2 for Haryana5 (20.7% for men and
0.1% for women) but lower than a previous study
conducted in Punjab, which reported a prevalence of
58.3%7 for men and 1.5% for women. In our study,
women did not report to consuming alcohol- a finding
that has also been shown by other studies 8,9.
Our study showed that women have a poorer
dietary pattern than men for all the age groups, which
may be a reflection of their poor social status10,11. It is
ironical that a low vegetable consumption is prevalent
in a predominantly vegetarian community. Developing
countries are undergoing various types of transitions-
epidemiological, socio-economic, demographic and
nutritional. Earlier developing countries had a high
prevalence of under-nutrition, but this era of transition
has also brought a double burden of under-nutrition
and over-nutrition in these countries12. Recent data
from NFHS 2 identified a significant proportion of
Indian women as overweight, coexisting with high rates
of malnutrition. However, the survey was confined only
to married women in reproductive age group and
showed a prevalence rate of 2.2% for women aged
15-49 years using BMI>30.0. The only representative
surveys are the ones conducted by the Food and
Nutrition Board (i.e. District Nutrition Profiles survey)
13, which have reported prevalence of 0.3% and 0.7%
in rural men and women respectively, using a BMI cut-
off of >30.0. The present study showed that 1.5% men
and 3.1% women have obesity. Our study draws
attention to the fact that there exists a pool of women
who were overweight in rural areas.
Our study showed that physical inactivity was
more common among women across all domains.
Maximum physical inactivity was during leisure time
while most men were physically active during transport.
This could be due to the fact that in rural areas bicycles
or walking are the still the usual mode of transport.
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
123
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Physical activity measurement at community level is
difficult with the existing instruments and therefore
these results would need to be interpreted with caution.
However it does appear that contrary to general
impression, physical inactivity is an emerging cause of
concern in rural areas of India.
Our findings show a high burden of hypertension
among elderly population. Men had a higher
prevalence than women in all age categories. Our
finding of 10.7% prevalence of hypertension in men
and 7.9% in women is lower than that observed in
other studies14. In a population-based survey carried
out during 1994-1995 in Raipur Rani block in the state
of Haryana, 4.5% were found to be hypertensive15.
Women had significantly higher prevalence of
hypertension than men (5.8% vs 3.0%). This is contrary
to our finding of lower prevalence of hypertension in
women as compared to men across all age groups.
Conclusion
Our study confirms the high burden of NCD risk
factors in rural areas and reiterates the need to address
these issues comprehensively as a part of NCD
prevention and control strategy. STEPwise approach
of WHO offers an entry point for low and middle
income countries to initiate NCD surveillance, as it
allows for the development of a flexible, increasingly
comprehensive and complex surveillance system
depending on local needs and resources3. Further
surveys are recommended based on this approach to
ensure data comparability over time and between
different sites. It is also important to study trends of
various risk factors and Ballabgarh offers a sentinel
site for such activity to be conducted in future.
Acknowledgement
This work presents the results of one of the five
sites of the multi-site initiative of ICMR and the authors
acknowledge the contribution of investigators of the
other four sites ( Dr. JC Mahanta, Dr. Thankappan,
Dr. V Mohan and Dr. Prashant Joshi) in its planning
and design. We also acknowledge the technical
guidance provided by WHO - particularly Dr. Cherian
Varghese ( WHO India), Dr. Jerzy Leowski WHO/
SEARO) and Dr. Ruth Bonita ( formerly with WHO/
HQ) and ICMR - Dr. Prashant Mathur and Dr. Geeta
Menon.
References
1. WHO. The World Health Report 2002- Reducing
risks, promoting healthy life. Geneva. WHO. 2002.
2. Ghaffar Abdul, Reddy K. Srinath, Singhi Monica.
Burden of non- communicable diseases in South
Asia. BMJ. 2004; 328:807-810.
3. WHO. STEPS: A Framework- The WHO
STEPwise approach to surveillance of
noncommunicable diseases (STEPS).WHO.
2002.
4. Chaudhry K. Prevalence of tobacco use in
Karnataka and Uttar Pradesh, India. Report.
2001.
5. International Institute for Population Sciences
(IIPS) and ORC Macro, India: National Family
Health Survey (NFHS-2), 1998-1999, Mumbai,
India: IIPS. 2000.
6. Sinha Dhirendra N, Gupta Prakash C, Pednekar
Mangesh S. Tobacco use in a rural area of Bihar,
India. Indian Journal of Community Medicine.
2003 Oct.-Dec; 28 (4): 167-70
7. Mohan D, Sharma HK, Sundaram KR, Neki JS.
Pattern of alcohol consumption in rural Punjab
men. Indian Journal of Medical Research. 1980;
72:702-711.
8. Sethi BB, Trivedi JK. Drug abuse in a rural
population. Indian Journal of Psychiatry. 1979;
21: 211.
9. Singh RB, Bajaj Sarita, Niaz Mohammad A,
Rastogi Shanty S, Moshiri M. Prevalence of type
2 diabetes mellitus and risk of hypertension and
coronary artery disease in rural and urban
population with low rates of obesity. International
Journal of Cardiology. 1998;66: 65-72.
10. United Nations Population Fund. The state of
world population 1997: the right to choose:
reproductive rights and reproductive health. New
York; UNFPA. 1997.
11. Anandalakshamy S. The Girl Child and the
Family. Department of Women and Child
Development, Ministry of HRD; Government of
India, Delhi. 1994.
12. Kapoor SK, Anand K. Nutritional transition: a
public health challenge in developing countries.
Journal of Epidemiology and Community Health.
2002; 56:804-805.
13. Government of India; Department of Women and
Child Development, Ministry of Human
Resources. India Nutrition Profile. New Delhi;
GOI. 1998.
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
124
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
14. Gupta R, Gupta HP, Keswani P, Gupta VP, Gupta
KD. Coronary heart disease and coronary risk
factor prevalence in rural Rajasthan. J Assoc
Physicians India. 1994;42:24-6.
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
15. Malhotra P, Kumari S, Kumar R, Jain S, Sharma
BK. Prevalence and determinants of hypertension
in an un-industrialised rural population of North
India. J Hum Hypertens. 1999 Jul; 13(7):467-72.
53rd Annual National Conference of IPHA
Organized by
Department of Community Medicine
Kempegowda Institute of Medical Sciences (KIMS), Bangalore - 560 070
Theme : Changing Public Health Scenario in the 21st century
Dates : 8th January, 2009 (Thursday) - Preconference CME
9th -11th January, 2009 - Conference
(Friday, Saturday& Sunday)
Venue : Kempegowda Institute of Medical Sciences (KIMS), Bangalore.
Registration fees
Only A/c Payee Demand Draft will be accepted, cheques will not be accepted. Demand Draft shall be in the name of
“53rd National Conference of IPHA”, payable at Bangalore. Please write your name, place, IPHA membership number
(for members) and mobile number on the reverse of the bank draft.
Category Before 01-11-2008 Spot 5
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IPHA member 1 Rs. 1500 Rs. 1800 Rs. 2300
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PG student (Non-member) 2Rs. 1000 Rs. 1400 Rs. 2000
Foreign delegates 4US$ 100 US$ 125 US$150
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(18000 for ( 24000 for (29000 for
10 Delegates) 10 delegates) 10 delegates)
Accompanying person6Rs 1000 Rs 1500 Rs 2000
(Spouse & Children only)
Pre-conference CME Rs 300 Rs 500 Rs 700
1. Quote IPHA membership number.
2. Recommendation letter from Head of Department / Head of Institution is compulsory.
3. Recommendation letter from Head of Department and only for those whose papers are accepted for presentation.
4. Or equivalent Indian currency.
5. Conference kit will be provided subject to availability.
6. Conference kit will not be provided.
Contact : Dr. B G Parasuramalu, Professor & Head
Organizing Secretary - 53rd Annual National Conference of IPHA,
Department of Community Medicine,
Kempegowda Institute of Medical Sciences (KIMS),
BSK 2nd Stage, Bangalore - 560070.
(M) 0-99860-03467
Email: iphacon09@kimsbangalore.edu.in
Websites: www.iphaonline.org ; www.kimscommunitymedicine.org
125
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Introduction
Disability is one of the major public health
problems of the developing countries, though the data
collected do not reflect the full extent of disability
prevalence1, 2, 3. This limitation results from the
conceptual framework adopted, the scope and
coverage of surveys undertaken, the definitions,
classifications and the methodology used for the
collection of data on disability. In India, the
implementation of the strategy for people with
disabilities as stated in the disability act 1995 is being
vigorously perused by the Ministry of Social Welfare
and all other concerned ministries4. Therefore it is
appropriate time to take stock of the situation of the
disabled population in the country specially in rural
sector where around 80% of the disabled persons
reside. Besides, prevalence studies will be useful tool
for developing community based rehabilitation
programmes for disabled. In view of the above context,
the present study was conducted to determine the
prevalence and pattern of disability in all age groups
in a rural community of Karnataka.
Original Article
Epidemiology of Disability in a Rural Community
of Karnataka
*K. S. Ganesh1, A. Das 2, J. S. Shashi 3
1Assistant Professor, Community Medicine, Kasturba Medical College, Mangalore, Karnataka; 2Professor, Community
Medicine, KS Hegde Medical College, Mangalore, Karnataka; 3Assistant Professor, Community Medicine, KMC,
Manipal, Karnataka. *Corresponding author: sssgan@yahoo.com.
Abstract
Objectives: To determine the prevalence and pattern of disability in all age groups in a rural
community of Karnataka. Methods: A community-based cross-sectional study was conducted
during January-December 2004 among 1000 study subjects of all age groups selected randomly
from four villages under rural field practice area of a teaching institution. Subjects were
interviewed and examined using a predesigned schedule. Percentage prevalence, chi square test
and multiple logistic regression analysis were used for statistical analysis. Results: The prevalence
of disability was found to be 6.3%. Both physical and mental disabilities are of great concrn in
this area. 80% of the disabled had multiple disabilities. Knowledge and occupation plays a major
role as determinants of disability. Chronic medical conditions are also more common among
disabled.
Key words: Disability, Epidemiology, Cross-sectional, Determinants.
Materials and Methods
This was a community-based cross sectional study
carried out over a period of 1 year from January to
December 2004. The study was conducted at the rural
field practice area of a teaching institution, which covers
a population of 45 000 spread over 11 villages of a
Taluk in Karnataka State of India. Four villages namely
Kotemattu, Yenegudda, Kidiyoor and Kadekar were
selected randomly for the present study. The population
covered by these four villages was 16,298. Sample size
was estimated for infinite population by using the
formula 4pq/d2, where prevalence was taken as 10%1.
Required precision of the estimate (d) was set at 20%.
Using the above formula, the sample size was estimated
to be 900. After adding non-response rate of 10%, an
additional 100 subjects were included. Thus 1000
subjects in all the age group were selected for this study.
Probability proportional to sampling technique
was used to select the study sample from each village.
In each of the four centers, all family folders were
arranged in a serial order. Then, the first folder was
126
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
selected randomly from the random number table and
the names of the eligible candidates from that
household noted down. Similarly, the next folder was
randomly picked up and the names of all the eligible
candidates of that household listed. This procedure
was repeated till the desired number of eligible persons
was achieved from each centre. Although households
were taken as cluster, the design effect would be
minimal considering the disability characteristics that
are different for members of the household. So, we
analysed the data taking individual as sampling unit.
The study was conducted by making house-to-house
visits, interviewing and examining all the individuals
in the family selected with pre-tested questionnaire.
Informed verbal consent was obtained from all
respondents. If a designated person could not be
contacted or not cooperative during three separate
visits, then the subject was considered as non-
respondent.
The demographic and other variables recorded
were age, sex, socio-economic status, marital status,
family type, literacy and occupation. Considering the
fact that the age, education and occupation are
important determinants of disability, we analysed the
data after sub categorization of each of these variables.
Socioeconomic status was assessed by modified
Uday Parik scale. Disability was assessed as per the
criteria laid down by WHO5. Mental disability was
assessed by Indian Disability Evaluation and
Assessment Scale (IDEAS) developed by the
Rehabilitation Committee of Indian Psychiatric
Society6. Disability below the age of 5 years was
assessed based on the instrument designed on the lines
of questionnaire taken from Action Aid India7. Chronic
medical conditions were assessed based on the
previous diagnosis. The data collected was tabulated
and analyzed by using the Statistical Package for Social
Sciences (SPSS) version 11.5 for windows. Chi square
test was carried out to test the differences between
proportions. To determine the independent effect of
various factors on disability, Multiple Logistic
Regression was performed.
Results
Of the 1000 subjects enrolled into the study, 954
subjects were available for the final analysis (response
rate 95%). Among them 472 (49.5%) subjects were males,
635 (67.5%) belonged to the age group of 15 – 59 years,
Table 1: Prevalence of disability
according to socio-demographic variables
(n=954)
Variables Total Prevalence χ2, p
Subjects No (%)
Gender
Male 472 24 (5.1) 2.3
Female 482 36 (7.5) 0.1
Age group (years)
< 5 72 0
5-14 122 1( 0.8)
15-59 635 30 (4.7) 74.2
≥ 60 125 29 (21.5) 0.001*
Socio-economic status
Low 456 34 (7.5)
Middle 486 26 (5.3) 1.8
High 12 0 0.2
Marital Status
Ever married 527 45 (8.5) 10.1
Never married 427 15 (3.5) 0.001*
Family Type
Nuclear 208 16 (7.7) 0.9
Joint/extended 746 44 (5.9) 0.3
Literacy † (years of schooling)
Illiterate 84 19 (22.6)
1-4 118 16 (13.6)
5-10 522 23(4.4) 52.4
> 10 125 1(0.8) < 0.001*
Occupation‡
Unemployed 104 30 (28.8)
Housewife 231 17 (7.4)
Unskilled 311 10 (3.2)
Skilled 40 1 (2.5)
Students 161 1 (0.6) 74.8
Professional 21 0 < .0001*
* P value less than 0.05 is considered as significant.
†105 (10.6%) subjects are below 7 years. Total number
of disabled among 7 years and above was 59.
‡ 86 (8.7%) subjects are below 6 years. Total number
of disabled among 6 years and above was 59.
Ganesh KS et al: Disability in a Rural Area of Karnataka
127
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
870 (92%) were literate, 746 (78.2%) belonged to joint/
extended family. About half of the study population
belonged to the middle socio-economic status (51%),
while only 1.3% (12) belonged to high socio-economic
status. 55.2% of the study subjects were ever married.
By occupation, 32.6% were unskilled workers/farmers/
petty business people; only 4.2% were skilled workers
and 2.2% professionals. Others were housewife (24.2%),
students (16.9%) and unemployed (10.9%).
The overall prevalence of disability was found to
be 6.3% (60/954). The most common type of disability
among the disabled was mental disability (22/60)
followed by loco motor (17/60), hearing (13/60),
speech (12/60) and visual (10/60) disability. 80% (48)
of the disabled had single disability and the rest 20%
had multiple disabilities.
The prevalence of disability among the elderly
group (>60 years) was very high (21.5%). As the age
advances, the prevalence increased significantly
(χ2=74.26, p=0.001).The present study showed that
40% (24) of the disabled were males and 60% (36)
were females. The prevalence of disability was
marginally higher among low socioeconomic and
nuclear family group. Among ever married group, the
prevalence was two and half times more than never
married group and the difference was found to be
significant (χ2=10.11, p=0.001). Nearly one quarter
of illiterates (22.6%) were disabled and those with
education level of above 10th standard had very low
prevalence. As literacy level increased, the prevalence
declined significantly (χ2=52.4, p= <0.001). Also, the
prevalence of disability among the unemployed was
very high (28.8%). The difference in prevalence of
disability between different occupation groups was
found to be statistically significant (χ2=78.846, p=
<0.0001). The present study revealed that half of the
disabled were unemployed, 28.3% were housewife and
16.7% were unskilled workers, farmers and people with
petty business (Table 1).
Majority of the disabled had joint pain and
backache (35, 58.3%). Hypertension was present in
30% (18) followed by asthma/COPD in 15% (9),
diabetes mellitus and fits in 10% (6) and heart problems
in 5% (3) of the disabled. Multiple logistic regression
analysis revealed that illiteracy, primary schooling and
unemployment had independent significant association
with the disability (Table 2).
Discussion
Well documented studies to determine the
prevalence and its epidemiological features are few.
Some studies had taken only the physical disability
and some others mental disability. Also, the data
collected by health workers could not detect mild
degrees of disability because of their limited knowledge
and lack of training. As our study illustrates, both
physical and mental disabilities are of great concern in
this area.
Also, knowledge and occupation plays a major
role as determinants of disability. Chronic medical
Table 2: Correlates of disability: Multiple
Logistic Regression analysis
Variables Odds ratio 95% CI P value
adjusted
Gender
Male - - -
Female 1.9 0.8-4.4 0.1
Age group (years)
< 45 - - -
45-59 0.8 0.3-2.7 0.8
≥ 60 2.3 0.8-6.1 0.1
Marital status
Never married - - -
Ever married 1.5 0.5-4.7 0.5
Literacy †(Years of schooling)
> 10 - - -
5-10 5.9 0.8-47.3 0.1
1-4 25.7 3.0-221.1 0.003*
Illiterate 29.9 3.3-269.2 0.002*
Occupation ‡
Professional - - -
& Skilled
Unemployed 15.9 1.8-138.2 0.012*
Housewife 0.9 0.1-8.9 0.9
Unskilled 1.3 0.1-10.7 0.8
Students 0.3 0.02-6.4 0.5
* P value < 0.05 is considered as significant; † 105
(10.6) subjects are below 7 years; ‡ 86 (8.7%) subjects
are below 6 years
Ganesh KS et al: Disability in a Rural Area of Karnataka
128
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
conditions are also more common among disabled.
World Health Organization estimates that 10%
of the world’s population has some form of disability1.
In contrast, recent National Sample Survey
Organization report2 and Census data 20013 revealed
prevalence as 2%.The present study showed a higher
prevalence of disability in comparison to prevalence
in general. This is because of detection of even mild
degrees of disability in our study. As per population
data provided by United Nations Population Fund
(UNFPA) Geneva 1995, the prevalence in India was
4.6%4. Higher prevalence of mental disability and the
proportion of people with multiple disabilities were
observed because of detection of even mild mental
disability in our study in contrast to other studies2,3,8,9.
The prevalence was more common among
geriatric age group. Our study findings are consistent
with the results of other studies2, 3,10. Marginally higher
prevalence of disability among females in contrast to
other studies might be due to favorable sex ratio in
this area 3, 10 . The present study showed that 75% of
the disabled were married and 25% of them were
unmarried in contradiction to other studies 8,3. In India,
about 92% of the disabled lived with their spouse and/
or other members in the family. But in the present study,
26.7% of the disabled belonged to nuclear family.
Others (73.3%) belonged to joint/extended family. In
view of the above, the disabled in this part of the
country are well placed as far as the family life is
concerned.
Disabled in this area are better educated when
compared to the disabled people of other areas3,8.
Various studies have shown that the prevalence of
disabilities is found to be significantly high among the
individuals suffering from chronic medical condi-
tions11,12.
It was observed by univariate analysis that the
age group, marital status, literacy, and occupation had
significant association with the disability. Age,
education and occupation all might act as confounders
in association of exposure variables of the study with
disability. The adjusted Odds Ratio (OR) for illiteracy
and primary schooling (1-4) revealed that the chance
of disability was 30 and 25.7 times respectively as
compared to those with education of above 10th
standard. Similarly adjusted OR for unemployment was
15.91 as compared to professionals and skilled. Thus
Multiple Logistic Regression analysis after accounting
for confounding factors showed that illiteracy; primary
schooling (1-4) and unemployment were considered
as significant factors in association with the disability.
Considering the fact that the population in this
study had a very high literacy rate and favorable sex
ratio, it is unlikely that the results are generalisable to
similar settings. We could not interview the non-
respondents because of their non-cooperation and non-
availability during our field visits. Since the proportion
of non-respondents was very small in our study
population, we expect only a minimal effect on our
prevalence estimate. There may have been recall bias.
Pure tone audiometry was not used while assessing
hearing disability due to feasibility constraints. In view
of the above findings it is concluded that the disabled
in this area need community assistance. There is an
ample scope for community based rehabilitation of the
disabled also.
References
1. World Health Organization .Training in the
community for people with disabilities. WHO:
Geneva; 1989.
2. National Sample Survey Organization. A report
on disabled persons. Department of Statistics,
Government of India: New Delhi; 2003.
3. Census of India 2001. Data on disability. Office
of the Registrar general India. (Serial online) 9
August 2004. Available from: URL:
www.censusindia.net/disability/disability_
mapgallery.html.
4. Sharma AK, Praveen V. Community Based
Rehabilitation in Primary Health Care System.
Indian Journal of Community Medicine 2002;
117: 139-142.
5. World Health Organization. International
Classification of Functioning, Disability and
Health: A manual of classification relating to the
consequences of disease. WHO: Geneva; 2001.
6. Govt. of India. Guidelines for evaluation and
assessment of mental illness and procedure for
certification. Ministry of Social Justice and
empowerment, Government of India. New Delhi,
2002.
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
7. Thomas M, Pruthvish S. Identification and needs
assessment of beneficiaries in community based
rehabilitation initiatives. Action Aid India,
Bangalore, 1993.
8. Noveymony MA, Raj SS. A study in the family
and socio-economic conditions of the persons
with disabilities in Vallioor Panchayat Union.
Asian Pacific Disability Rehabilitation Journal
2003; 5(1): 14-20.
9. Kishore MT. Psychiatric diagnosis in persons with
intellectual disability in India. Journal of
Intellectual Disability Research Jan.2004; 48(1):
19-24.
10. Alan MJ, Branch LG. The Framingham Disability
Study. American Journal of Public Health 1981;
71(11): 1211-1216.
11. Joshi K, Kumar R, Avasti A. Morbidity profile and
its relationship with disability and psychological
distress among elderly people in northern states.
Int. Journal of epidemiology Dec. 2003; 32(6):
978-987.
12. Dey AB, Shubha S, Kalpana MN, Jhingan HP.
Evaluation of the health and functional status of
older Indians as a preclude to the development
of a health programme. The National Medical
Journal of India 2001; 14(3): 135-138.
Ganesh KS et al: Disability in a Rural Area of Karnataka
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130
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Introduction:
Iodine deficiency disorders (IDD), spectrum of
health consequences due to iodine deficiency are still
major public health problems in many countries. One
of the most common preventable causes of mental
retardation in the world today is iodine deficiency1, 2.
An estimated 1571 million people worldwide lives in
iodine-deficient environment, and is at risk of IDD3.
In India, about 167 million people are estimated to be
at risk for IDD, of which 54 million have goitre and
over 8 million have neurological deficits 4. Earlier 275
districts in the country have been surveyed for IDD
and 235 districts have been found to be endemic5.
For prevention and control of IDD iodisation of
salt is widely recognised as the most effective and
Original Article
Elimination of Iodine Deficiency Disorders – Current Status in
Purba Medinipur District of West Bengal, India
A. B. Biswas1, I. Chakraborty2, *D. K. Das3, A. Chakraborty4, D. Ray5, K. Mitra6
1Professor, Community Medicine, B. S. Medical College, Bankura, 2Professor, Biochemistry, Medical College, Kolkata;
3Associate Professor, 4Demonstrator, Community Medicine, R. G. Kar Medical College, Kolkata; 5Assistant Professor,
Biochemistry, Medical College, Kolkata; 6 Health and HIV specialist, UNICEF, Kolkata, West Bengal.
*Corresponding Author: dilip_shampa@hotmail.com, drdilipkumardas@gmail.com
sustainable long-term public health measure6 and is
being implemented in many countries. In India,
compulsory salt iodisation was initiated in 1998 but it
was revoked in 2000. However, the government of
India from 15th August 2005 has once again imposed
the ban on sale and production of non-iodised salt.
Besides this, since 1992, IDD control programme has
been in operation in all the states of India, including
West Bengal with the aim of eliminating IDD as a public
health problem.
However, International Council for the Control
of Iodine Deficiency Disorders (ICCIDD), WHO and
UNICEF recommend the progress of such programme
in any country needs to be monitored using quantifiable
indicators 7. The indicators include: 1. Proportion of
households consuming effectively iodised salt (>90%);
Abstract
Background and Objectives: Towards sustainable elimination of iodine deficiency disorders
(IDD), the existing programme needs to be monitored through recommended methods and
indicators. Thus, we conducted the study to assess the current status of IDD in Purba Medinipur
district, West Bengal. Methods: It was a community based cross-sectional study; undertaken
from October 2006 - April 2007. 2400 school children, aged 8-10 years were selected by ‘30 cluster’
sampling technique. Indicators recommended by the WHO/UNICEF/ICCIDD were used. Subjects
were clinically examined by standard palpation technique for goitre, urinary iodine excretion
was estimated by wet digestion method and salt samples were tested by spot iodine testing kit.
Results: The total goitre rate (TGR) was 19.7% (95% Cl = 18.1 – 21.3 %) with grade I and grade II
(visible goitre) being 16.7% and 3% respectively. Goitre prevalence did not differ by age but
significant difference was observed in respect of sex. Median urinary iodine excretion level was
11.5 mcg/dL and none had value less than 5 mcg/dL. Only 50.4% of the salt samples tested were
adequately iodised (≥ 15 ppm). Conclusion: The district is in a phase of transition from iodine
deficiency to iodine sufficiency as evident from the high goitre prevalence (19.7%) and median
urinary iodine excretion (11.5mcg/dL) within optimum limit. But, salt iodisation level far below
the recommended goal highlights the need for intensified efforts towards successful transition.
Key Words: Iodine deficiency, Goitre, IDD, Urinary iodine, Iodised salt
131
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
2. Urinary iodine: proportion below 100 mcg/lt (<50%)
and proportion below 50 mcg/lt (<20%) and 3.
Thyroid size: proportion of school children 6-12 years
age with enlarged thyroid, by palpation or ultrasound
(<5%).
Using these indicators and prescribed
methodologies by WHO, UNICEF and ICCIDD; during
the recent years, studies had been done in six districts
(Malda, Birbhum, Dakshin Dinajpur, North 24
Parganas, Purulia and Howrah) of the state 8-13. These
studies have reported mild to moderate goitre
prevalence in the surveyed districts and variable
proportion of adequately iodised salts. In this context,
it was decided to have more objective and scientifically
valid data in other districts of the state. We thus
conducted the present study to assess the status of IDD
in Purba Medinipur district of West Bengal with the
following objectives: to find out the prevalence of goitre
among school children aged 8 to10 years in Purba
Medinipur district, to determine the status of urinary
iodine excretion (UIE) levels of school children aged 8
to 10 years in the district and to assess iodine content
of salts at the household level in the district.
Materials and Methods
It was a cross-sectional, school-based study
conducted during October 2006 to April 2007 in Purba
Medinipur district, West Bengal. The study population
was school children of 8-10 years of age. We included
this age group because of their combined high
vulnerability to disease, easy accessibility &
representative ness of their age group in the community.
This age group are recommended for assessment of
IDD7.
No previous data was available on prevalence of
goitre in Purba Medinipur district. Thus, the sample
size of children to be surveyed was based on the
assumed goitre prevalence rate of 50%, 95%
confidence interval (CI), a design effect of 3 and a
relative precision of 10%. Using these parameters a
sample size of 1200 was obtained. But as our intention
was to assess the degree of severity also, we decided
to double the calculated sample size; thus the final
sample size was 2400 children in the age group of 8 -
10 years i.e. 80 per cluster in a 30 cluster sampling
technique7.
Multistage cluster sampling methodology was
followed for selecting the study population. We enlisted
all the rural & urban population units in the district
with their respective population. The 30 clusters i.e.
population units (villages/urban wards) to be surveyed
were selected using “probability proportional to size”
(PPS) sampling method. In each identified cluster all
the primary schools were enlisted and simple random
sampling was used to select one school for detailed
survey. From the sampling frame of all children
between 8-10 years of the selected school, 80 children
were selected following simple random sampling
technique for inclusion in the study. If the sample could
not be covered in the school, adjoining school was
included to complete the sample of the cluster. Thus a
total of 2400 school children were included in the study.
Prior intimation was given to the identified school
authority one week before the survey to ensure
attendance of students. The schoolteachers and
children were also briefed about the activities to be
undertaken during the survey. A pre-designed pre-
tested schedule was used for data collection.
Investigators comprised of faculty members from the
Department of Community Medicine, R. G. Kar
Medical College, Kolkata and Department of
Biochemistry, Medical College, Kolkata, West Bengal.
An initial training was imparted to minimise inter
observer variation during the survey.
Assessment of goitre: The size of the thyroid was
determined clinically by standard palpation method
and grading of goitre was done according to the criteria
recommended by the joint WHO/UNICEF/ICCIDD
(Grade 0: No palpable or visible goitre. Grade I: A
mass in the neck that is consistent with an enlarged
thyroid that is palpable but not visible when the neck
is in normal position. It moves upwards in the neck as
the subject swallows. Grade II: A swelling in the neck
that is visible when the neck is in a normal position
and is consistent with an enlarged thyroid when the
neck is palpated) 7, 14. Goitre grades I and II together
considered as the Total Goitre Rate (TGR).
Estimation of urinary iodine excretion level: The
recommended sample size for collection of biological
specimens, such as urine, is 300 (i.e. 10 children x 30
clusters) 14. Considering 20% dropout/wastage, final
sample size of urine samples was decided to be 360
Biswas AB et al: IDD in Purba Medinipur, West Bengal
132
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
(i.e. 12 children x 30 clusters). In the present study,
systematic random selection was used to select 12
children from each school for urine collection, among
those who were clinically examined. Thus, 360 casual
on the spot urine samples (0.5 to 1.0 ml) were collected
in wide-mouthed screw capped plastic bottles (one
drop of toluene was added to inhibit bacterial growth
and to minimise odour) and stored in a refrigerator at
4oC until analysis. Six urine samples were wasted and
finally 354 samples were available for analysis. The
Urinary Iodine Excretion (UIE) level was measured by
wet digestion method15. The result was expressed as
mcg iodine/dL urine.
Assessment of iodine content of salt: In each
cluster, all the study children were asked to bring about
20 gm of salt which were routinely being consumed in
their respective families. In the present study, Iodine
content of 2400 salt samples was estimated using spot
iodine testing kit.
The data entry and analysis was done at R.G.Kar
Medical College, Kolkata. We entered the data in
Microsoft Excel and analysed accordingly to find out
the outcome variables.
Results:
Characteristics of the study population:
Of 2400 study children, 47.5% (1139) were males
and 52.5% (1261) females. About 33.5% (805), 32.7%
(785), 33.8% (810) of them belonged to eight, nine
and ten years of age respectively. Most of the children
were from rural area (93.3%, 2240/2400) and Hindu
by religion (79%, 1896/2400).
Prevalence of goitre:
Table 1 depicts the prevalence of goitre in Purba
Medinipur district.
Overall total goitre prevalence rate (TGR) was
19.7% (95% Cl =18.1 – 21.3 %), of which16.7% and
3.0% was grade I and grade II (visible goitre)
respectively. Goitre prevalence among girls (22.4%)
and boys (16.7%) was significantly different (χ2 =
12.55, d.f. = 1, p=0.0003). Overall age specific goitre
prevalence among 8, 9 and 10 years old children
were17.5%, 20.3% and 21.4% respectively; the
difference was not statistically significant (χ2 =3.99,
d.f. = 2, p=0.136).
Urinary iodine excretion level:
We analysed 354 urine samples for urinary iodine
excretion (UIE) levels. Urinary iodine excretion levels
for 83 (23.4%) of the children were in the mild range
(5 – 9.9 mcg/ dL) of iodine deficiency. No children
had UIE value in the moderate or severe range of iodine
deficiency. 76.6% children had urinary iodine above
the recommended level of ≥ 10 mcg/dL (Table 2). The
median UIE level was 11.5mcg/dL (range = 7.5 – 18
mcg/dL).
Iodine content of salts:
In the present study, 2400 salt samples were tested
with spot iodine testing kit.
It was revealed that salt with nil iodine content
was consumed by 17.7% of the beneficiaries and
another 32% consumed salt with iodine content of <15
ppm. Half of the households (50.4%) had adequate
iodine content of ≥ 15 ppm (Table 3).
Biswas AB et al: IDD in Purba Medinipur, West Bengal
Table 1: Goitre prevalence by age and sex in Purba Medinipur district, West Bengal
(n=2400)
Male(n=1139) Female(n=1261) Combined(n=2400)
Age (Years) Goitre Grade Goitre Grade Goitre Grade
I II TGR I II TGR I II TGR
No. (%) No. (%) No. (%)
8 (n=805) 49 5 54 (13.2) 77 10 87 (22.0) 126 15 141(17.5)**
9 (n=785) 57 4 61(17.2) 84 14 98 (22.8) 141 18 159(20.3)**
10 (n=810) 59 16 75 (20.1) 74 24 98 (22.5) 133 40 173(21.4)**
All (n=2400) 165 25 190 (16.7)* 235 48 283 (22.4)* 400 73 473(19.7)
* χ2 = 12.55, d.f. = 1, p=0.0003 ** χ2 = 3.99, d.f. = 2, p= 0.136
133
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Discussion:
In the present study, an overall goitre prevalence
rate of 19.7% was found, signifying that the district
Purba Medinipur is mildly endemic for iodine
deficiency. However, recent studies in six other districts
of the state viz. Malda, Birbhum, Dakshin Dinajpur,
North 24 Parganas, Purulia and Howrah using
standard methodology, as has been followed in the
present one, revealed prevalence of 11.3%, 12.6%,
18.6%, 20.1%, 25.9% and 13.7% of goitre
respectively8-13. But less than 5% TGR was found in
9 out of 15 districts studied in 11 states by an Indian
Council of Medical Research (ICMR) study 16.
Urinary iodine concentrations are the most
reliable indicator of IDD. The WHO/UNICEF/ICCIDD
have also recommended that no iodine deficiency be
indicated in a population when median urinary
excretion level is 10 mcg/dL or more i.e. more than
50% of the urine samples have UIE level of ≥ 10 mcg/
dL and not more than 20% of the samples have UIE
level of less than 5 mcg/dL7.
In Purba Medinipur district, we found a desirable
value for both these two indicators. Median UIE level
(11.5 mcg/dL) was more than the minimum
recommended level of 10 mcg/dL. Overall, 76.6% of
the children had UIE levels in the ranges of optimal
iodine nutrition (≥ 10 mcg/dL), and none had
concentrations <5 mcg/dL. These results indicate that
current iodine deficiency does not exist in Purba
Medinipur district. Similar median values of urinary
iodine in the desirable range of ≥ 10 mcg/dL were also
observed by most of the studies in other districts of
West Bengal 8-11, 13 and also other states 17- 22.
However, median urinary iodine values less than the
recommended level was reported from three districts
in other states (Lakhimpur Kheri and Mainpuri in Uttar
Pradesh and Gaya in Bihar) 16 and also from Purulia
district of West Bengal 12.
Analysis of the urinary iodine excretion in the
present study indicated inadequate intake of iodine
by a substantial proportion of children, which was not
at all unexpected as analysis of salt samples also
revealed around 50% of the children consumed non-
iodised/inadequately iodised salt.
We found, only 50.4% of the children were
consuming adequately iodised salt (≥ 15 ppm), which
is far below the recommended goal of > 90% coverage
7. Compared to this, less proportion was found in
Birbhum (37.2%) and Purulia (33.4%) district 9, 12,
but much higher proportion was reported from other
districts viz. 67.4%, 70%, 80% and 85% in Dakshin
Dinajpur, North 24 Parganas, Howrah and Malda
respectively 10, 11, 13, 8.
For monitoring progress towards elimination of
IDD, the recommended parameters are to be
interpreted cautiously. There may be discrepancies
between urinary iodine concentrations and prevalence
of goitre, because urinary iodine excretion level reflects
the current iodine status, while the prevalence of goitre
indicates the long-term iodine status in a population23.
Findings of high TGR and optimal urinary iodine
excretion have been reported in most of the earlier
studies in India 8-11, 13, 17 - 22 reflecting a transition
from iodine deficient to iodine sufficient state.
Observation in Purba Medinipur corroborates with
most of the other districts in the state. However,
consumption of iodine from sources other than iodised
salts needs also to be studied.
Conclusion:
High TGR of 19.7% indicates that the Purba
Medinipur district is mildly endemic for IDD. But,
median urinary iodine (11.5 mcg/dL) reflects no
Table 2: Urinary Iodine Excretion levels
in the study population in Purba
Medinipur district, West Bengal (n = 354)
Urinary Iodine Excretion Number Percentage
levels (mcg/dL)
< 5.0 0 0
5.0 – 9.9 83 23.4
≥ 10 271 76.6
Table 3: Iodine content of salts at
household level in Purba Medinipur
district, West Bengal (n = 2400)
Iodine content Number Percentage
of salts (ppm)
Nil 424 17.7
< 15 767 31.9
≥ 15 1209 50.4
Biswas AB et al: IDD in Purba Medinipur, West Bengal
134
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
existence of current iodine deficiency. Interpreting these
two indicators together, it may be concluded that the
district Purba Medinipur is in a state of transition from
iodine deficiency to iodine sufficiency. However,
adequately iodised salt consumption at the household
level (50.4%) is far below the recommended goal of
>90%. Towards sustainable elimination of IDD,
awareness generation for both sale and consumption
of iodised salt, regular monitoring at household and
retailer level through involvement of different sectors
need to be strengthened.
Acknowledgements
We acknowledge the support and cooperation of
the district authorities, Department of Health and
Family Welfare as well as Department of Primary
Education, Purba Medinipur district, West Bengal. The
school authorities and children of the surveyed schools
deserve special mention for their help and much
needed cooperation during actual conduct of the study.
We express our sincere gratitude to the Department of
Health and Family Welfare, Government of West
Bengal and UNICEF, Kolkata, West Bengal for their
financial and other support to carry out the study
smoothly.
References :
1. Hetzel BS. S.O.S. for a billion – the nature and
magnitude of the iodine deficiency disorders.
In: Hetzel BS, Pandav CS, Eds. S.O.S. for a
billion. The conquest of iodine deficiency
disorders. Delhi, Oxford University Press; 1996,
pp 3 -29.
2. Kapil U. Goitre in India and its prevalence.
Journal of Medical Sciences and Family Planning,
1998, 46 – 50.
3. United Nations Children’s Fund. The state of the
world’s children: focus on nutrition. New York,
Oxford University Press; 1998, pp 15 – 20.
4. Ramji S. Iodine deficiency disorders -
epidemiology, clinical profile and diagnosis. In:
Nutrition in children - developing country
concern; Editors: H. P. S. Sachdev, Panna
Choudhury, Department of Paediatrics, Moulana
Azad Medical College, New Delhi, 1995, 245 –
254.
5. WHO. Eliminations of iodine deficiency disorders
in South East Asia, SEA/NUT/138, 1997, 1-8.
6. Manner VMG. Control of iodine deficiency
disorders by iodination of salt: strategy for
developing countries. In: Hetzel BS, Dunn JT,
Stanbury JB, eds.The prevention and control of
iodine deficiency disorders. Amsterdam, Elsevier,
1987: 111- 125.
7. Joint WHO/UNICEF/ICCIDD Consultation:
Indicators for assessing iodine deficiency disorders
and their control programmes, Geneva, WHO,
1992.
8. Biswas AB, Chakraborty I, Das DK, Biswas S,
Nandy S. and Mitra J. Iodine deficiency disorders
among school children of Malda, West Bengal,
India. J Health Popul Nutr 2002 Jun; 20 (2): 180-
183.
9. Biswas AB, Chakraborty I, Das DK, Roy RN,
Mukhopadhaya S and Chatterjee S. Iodine
deficiency disorders among school children of
Birbhum, West Bengal. Current Science 2004; 87
(1): 78 - 80.
10. Das DK, Chakraborty I, Biswas AB, Sarkar GN,
Shrivastava P, and Sen S. Iodine deficiency
disorders among school children of Dakshin
Dinajpur district, West Bengal. Indian Journal of
Public Health, April-June 2005; 49(2): 68-72.
11. Sen TK, Biswas AB, Chakrabarty I, Das DK,
Ramakrishnan R, Manickam P, Hutin Y.
Persistence of Iodine Deficiency in Gangetic
Flood-Prone Area, West Bengal, India. Asia
Pacific Journal of Clinical Nutrition 2006; 15(4):
528 -532
12. Biswas AB, Chakraborty I, Das DK, Roy RN, Ray
S and Kunti SK. Assessment of iodine deficiency
disorders in Purulia district, West Bengal, India.
Journal of Tropical Paediatrics 2006; 52 (4): 288
- 292.
13. Das DK, Chakraborty I, Biswas AB, Saha I,
Majumder P and Saha S. Assessment of iodine
deficiency disorders in Howrah district, West
Bengal, India. (Personal Communication).
14. Kumar S. Indicators to monitor progress of
National Iodine Deficiency Disorders Control
Biswas AB et al: IDD in Purba Medinipur, West Bengal
135
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Programme (NIDDCP) and some observation on
iodised salt in West Bengal. Indian Journal of
Public Health 1995; 39 (4): 141-147.
15. Dunn JT, Crutchfield HE, Gutekunst R and Dunn
D. Methods for measuring iodine in urine. A joint
publication of WHO/UNICEF/ICCIDD, 1993, 18-
23.
16. Toteja GS, Singh P, Dhilon BS and Saxena BN.
Micronutrient deficiency disorders in 16 districts
of India: part 1 report of an ICMR task force study
– district nutrition project. ICMR; New Delhi,
2001, pp 1- 22.
17. Kapil U. Editorial: Current status of Iodine
Deficiency Disorders Control Programme,
Indian Paediatrics 1998; 35: 831-836.
18. Sohal KS, Sharma TD, Kapil U, Tandon M.
Assessment of iodine deficiency in district
Hamirpur, Himachal Pradesh. Indian
Paediatr1998; 35:1008-1011.
19. Bhardwaj AK, Kapil U. Assessment of iodine
deficiency in district Bikaner, Rajasthan. Indian J
Matern Child Hlth 1997; 8:18-20.
20. Sohal KS, Sharma TD, Kapil U, Tandon M.
Current status of prevalence of goitre and iodine
content of salt consumed in district Solan,
Himachal Pradesh. Indian Paediatr1999;
36:1253-1256.
21. Kapil U, Sohal KS, Sharma TD, Tandon M and
Pathak P. Assessment of iodine deficiency
disorders using the 30 cluster approach in district
Kangra, Himachal Pradesh. Journal of Tropical
Pediatrics, October 2000: 264 – 266.
22. Kapil U, Sethi V, Goindi G, Pathak F, Singh P.
Elimination of iodine deficiency disorders in Delhi.
Ind. J Paediatr 2004; 71 (3): 211 – 212.
23. Sebotsa MLD, Dannhauser A, Jooste PL, and
Joubert G. Prevalence of goitre and urinary iodine
status of primary school children in Lesotho.
Bulletin of the World Health Organiztion 2003;
81 (1): 28 – 34.
Biswas AB et al: IDD in Purba Medinipur, West Bengal
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Notice for 53rd Annual Central Council Meeting
The 53rd Annual Central Council Meeting of the IPHA will be held on 8th January, 2009 at 6 PM
at Meeting Hall of Kempegowda Institute of Medical Sciences (New Campus), Banashankari 2nd stage,
Bangalore -560 070. (Please reconfirm the exact venue and time from the organizers of the conference)
Sd/-
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Secretary General, IPHA
136
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Introduction
Three years of implementation of IDSP has taught
many lessons. In the course of implementation, a few
Special Article
Integrated Diseases Surveillance Project (IDSP)
Through a Consultant’s Lens
*K. Suresh1,
1Public Health (Child) Consultant, New Delhi. *Correspondence: ksuresh@airtelmail.in, ksuresh.20@gmail.com
practical modifications have been affected. This article
looks at the implementation challenges of each of the
activities originally planned under IDSP and the
changes that occurred over this period as observed by
Summary
India has long experienced one of the highest burdens of infectious diseases in the world, fueled
by factors including a large population, high poverty levels, poor sanitation, and problems with
access to health care and preventive services. It has traditionally been difficult to monitor disease
burden and trends in India, even more difficult to detect, diagnose, and control outbreaks until
they had become quite large.
In an effort to improve the surveillance and response infrastructure in the country, in November
2004 the Integrated Disease Surveillance Project (IDSP) was initiated with funding from the World
Bank. Given the surveillance challenges in India, the project seeks to accomplish its goals through,
having a small list of priority conditions, many of which are syndrome-based at community and
sub center level and easily recognizable at the out patients and inpatients care of facilities at
lowest levels of the health care system, a simplified battery of laboratory tests and rapid test kits,
and reporting of largely aggregate data rather than individual case reporting. The project also
includes activities that are relatively high technology, such as computerization, electronic data
transmission, and video conferencing links for communication and training.
The project is planned to be implemented all over the country in a phased manner with a stress
on 14 focus states for intensive follow-up to demonstrate successful implementation of IDSP.
The National Institute of Communicable Diseases chosen to provide national leadership may
have to immediately address five issues. First, promote surveillance through major hospitals
(both in public and private sector) and active surveillance through health system staff and
community, second, build capacity for data collation, analysis, interpretation to recognize warning
signal of outbreak, and institute public health action, third, develop a system which allows
availability of quality test kits at district and state laboratories and /or culture facilities at identified
laboratories and a national training program to build capacities for performing testing and
obtaining high quality results, fourth, there must be a process established by which an appropriate
quality assurance program can be implemented and fifth, encourage use of IT infrastructure for
data transmission, analysis, routine communication (E-mail etc) and videoconferencing for
troubleshooting, consultations and epidemiological investigations. These five activities must be
addressed at the national level and cannot be left up to individual states/districts.
Keywords: Surveillance, syndrome case, probable case, laboratory confirmed case, epidemic,
public health action, rapid test kits.
137
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
the consultant in the course of his association with the
project since March 2006.
Administrative Structure of IDSP:
In January 2007 the project was restructured to
provide nearly half of the total credit (SDR 21.53
million) for urgent financing requested by Government
of India (GOI) for Avian Influenza pandemic prevention
and control.
The realization of operational ease has led to
relocating the administrative unit located in the ministry
of health and family welfare (under a Joint secretary)
to National Institute of Communicable Diseases (NICD)
under the leader ship of its Director in 2006-07. This
arrangement facilitated utilizing the services of about
half dozen officers (epidemiologists, microbiologists
and statistical officers) to support dedicated National
Program Officer in ensuring enhanced technical
support, improved state’s oversight and trouble
shooting.
Under the project surveillance units have been
established at national, state and district levels in 23
states covered under first two phases and the process
is underway in phase III states. The operational
manuals have been prepared and to a large extent the
planned training of the health staff has been completed
in these 23 states. An effort to enhance coordination
with national disease control programs has begun with
rationalization of fever reporting forms with the
National Vector Borne Diseases Control program.
The project depended on state for technical
human resources {complimenting only information
technology (IT) and support staff on contractual basis}.
Lack of ownership and quick turn over of the state
staff was a challenge and hindering the pace of the
progress of the project during first three years. Making
IDSP as part of National Rural Health Mission has the
biggest gain of 2007-08, leading to creation of 766
dedicated professional positions (Epidemiologist,
Microbiologists, and Entomologists) under NRHM at
central, state and district level. While it created a good
opportunity for the professionals (especially Public
Health /Epidemilogists), recruitment of qualified people
and their orientation for the project activities is going
to be challenge for the coming years.
Project Implementation: Project imple-
mentation has been lagging by about a year. Third
phase states started activities only in later part of 2007-
08. Training of phase I districts have been completed
and those in phase II are near completion. Supplies of
phase one is complete and that for phase II and III is
decentralized. Adaptation of information technologies
is taking shape, Call Center 24x7 (unique NO: 1075)
is functional since beginning of 2008 and
videoconferencing with most of the state headquarters
is established. However the electronic online data entry,
analysis and transmission have not yet begun.
Establish and operate a Central Surveillance
Unit (CSU):
Central Surveillance Unit will support and
complement the state surveillance units (SSUs): Central
surveillance unit by now is well established and
supported by dedicated NICD officers to the state for
periodical visits. Most states were visited 1-2 times as
against expected quarterly visits. The quality of review,
trouble shooting and facilitating action needs to be
improved.
Prepare national guidelines for disease
surveillance, select priority conditions for surveillance,
and standard case definitions for each of them and
methods for surveillance: This task was completed in
2006, but some implementation hurdles like difficulty
in collecting passive surveillance data, desegregation
of data by age and gender were noted. Revision of
syndromic (‘S’) and probable (“P”) forms by including
only select priority specific conditions and eliminating
desegregation of data by age and gender recently
would facilitate surveillance.
Coordinate timely transport of specimens to the
regional, national and international laboratories: This
task is happening as it used to before IDSP through
NICD Microbiology section
Analyze data, identify epidemiological trends and
prepare national epidemiological situation reports: The
data is being received from about 250 districts of phase
I &II states and periodical analysis is being done since
third quarter of 2007-08. The first national
epidemiological annual report (2006) is ready and the
one for 2007 is getting ready.
Coordinate Quality Assurance Surveys: Base line
quality of laboratories has been completed and internal
quality standards along with waste management
guideline have been shared. The quality of training by
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
master training institutes has been evaluated externally
and suitable actions being taken on the
recommendations. The key recommendations include
more hands on training particularly in filing up the
forms of reporting, better participatory teaching
approaches, more exposure to real field situations and
better involvement of the microbiologists/laboratory
technicians.
Integrate and strengthen disease surveillance
at State and Districts level:
A. State-level:
i) Establish state surveillance unit (SSU): Each State
will establish a SSU headed by technical officer,
supported by 3 technical consultants (training,
finance and procurement ) and 4 support staff from
project (data entry operators-2, office assistant and
accountant).
All the states in phase I and II have already
established the SSU’s and most in phase III also have
established the SSU’s. The major hurdle has been the
continuity in the State technical officers. As it is a senior
level post quick turn over is seen due to superannuation
/ promotion. It is also a fact that this level officer has
many other responsibilities and hence not able to give
more than 20-25% of his/her time for IDSP. As far as
the contractual posts are concerned majority of them
are filled up in Phase I and II but there is big turn over
due to temporary nature of the post and low pay
package. It has been very difficult to get public health
consultant and the financial consultants at state level.
ii) The emphasis is on integration of disease
surveillance activities, laboratory coordination,
and involvement of private sector, non
governmental organizations (NGOs) and
community.
Most of the state level officers are struggling in
settling their own house (Govt. set up) right, attention
to surveillance activities; laboratory coordination and
involvement of private sector etc are not getting priority.
iii) SSU will prepare and send weekly/monthly
summaries of the disease situation to CSU.
While most SSUs in phase I & II have been able
to send monthly collated surveillance information from
their districts, only about half of them are sending
weekly summaries to the CSU. However large numbers
of districts are sending weekly reports directly to the
CSU also.
iv Train state and district level staff;
All the states in phase I have completed the
training as per their PIP whereas most in phase II are
nearing completion of training of staff as envisaged in
PIP. All the states had initially given high priority to
rural health staff @ one worker per sub-center and @
one doctor per PHC because of administrative
convenience and no efforts were made to train hospital
and dispensary doctors, nurses and pharmacists.
Therefore the district, sub-district and major hospital
surveillance is not really established. Realizing the
limitation States like Tamil Nadu, Gujarat and
Karnataka were able to complete the training of all the
staff involved in surveillance activities in 2007 and
demonstrate the utility. All states by now have realized
the need for training of staff involved in IDSP from
hospitals, doctors, pharmacists and laboratory
technicians and male health workers in sub center and
are planning for the same in the 2008 activities.
v) Implement periodical non-communicable disease
surveys/and or their risk factors
The project has envisaged periodical household
surveys by states (one third of states each year by
rotation) once in 3-4 years. The surveys would capture
behavioral variables (like smoking, alcohol
consumption etc) to mount national/state specific
advocacy and behavior change communication
strategies. Negotiations between NICD and Indian
Council of Medical Research (ICMR) took longer time
than expected and the actual survey was delayed and
likely to be completed by September 2008 for the first
generation of 8 states.
vi) Support districts in data analysis, transport
specimens, and outbreak investigations.
The SSU’s have been supporting outbreak
investigations and specimen transportations. However,
SSUs are still not in a position to support data analysis
as the requisite software is not yet developed by the
National Informatics Center (NIC).
vi) Oversee the implementation of IDSP, monitor
quality of laboratory services etc.
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Due to quick turn over of both the regular state
surveillance officer (SSO) and the contractual technical
staff the mechanism of oversight and monitoring of
the laboratory services is poor.
District level:
i) Establish district surveillance unit (DSU): Each
State will establish a DSU in each district headed
by medical graduate with a background of Public
health, supported by one microbiologist and 4
support staff from project (data entry operators-
2, office assistant and accountant).The emphasis
is on integration of disease surveillance activities,
laboratory coordination, and involvement of
private sector, NGOs and community.
All the states in Phase I &II and some in phase III
have established DSU by now. District Vector Borne
Diseases control Medical officers or a Deputy Chief
Medical (Additional /Assistant) officer of Health at the
District Chief Medical office (District Health and Family
Welfare Office) has been given additional responsibility
of IDSP. This again is an impediment for the progress
of the project as the officer is able to give about one
thirds of his time only. It is also a fact that most of
these officers do not have public health background.
Lack of qualified microbiologists at the district level
(except in Karnataka and Maharashtra) has left the
oversight and coordination responsibility of
laboratories loose. One thirds of the district are able
to involve private sector that too on a small scale.
Majority of the districts surveillance units with medical
colleges have not been able to negotiate with them for
a productive partnership for surveillance and improved
diagnostic capabilities. Integrating the surveillance at
the district level is a distant dream due to different
developmental status of vertical programs like national
vector borne disease control program (NVBDCP),
national tuberculosis control program ( NTCP) etc.
ii) Analyzing the surveillance data from the
peripheral institutes and providing feedback.
Most of the districts are able to input the data
online. Analyzing surveillance data and feedback
during monthly meetings and on visit to the peripheral
units has started in states like Gujarat, Tami Nadu,
Karnataka, Uttarkhand.
iii) Train sub-district health staff
Training of the health staff at the primary health
center (PHC)s and sub-centers has been completed in
phase I & near completion in phase II. The staff
(doctors, pharmacists and lab technicians etc) at the
district and sub-district hospitals was taken up in late
2007 and being intensified in 2008.
iv) Initiate investigation of suspected cases/outbreaks
& institute public health action.
Investigation of suspected cases and out breaks
has been initiated in majority of the districts. Identifying
the outbreak from routine reporting (based on alert of
more than expected cases) and taking investigation is
still wanting. On outbreak investigation public health
action is invariably taken.
v) Support for collection and transport specimens
to laboratory networks
The specimen collection and transportation in a
district is mainly done by the district staff.
vi) Responding promptly to the information provided
by the community.
The system of recording the community
information and responding is yet to be developed.
Community Level:
i) Notify the nearest health facility of a disease or
health condition selected
There is no official formalization of community
reporting, though sometimes community does report
to the nearest PHC. Use of call center is limited to
health staff only.
ii) Support health workers during outbreak
investigations
Most communities do support during outbreak
investigations for fear of spread of disease.
iii) Community mobilization and empowerment for
community participation in containment
measures.
Community mobilization and empowerment of
community participation for containment measure is
still a distant dream.
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Strengthen data quality, analysis and links to
action:
i) ‘Real-time’ on-line entry, management and
analysis of surveillance data using computers,
internet and www:
Real-time on line entry of data at the district level
is happening in phase I & II districts. Collation, analysis
using computers and internet is waiting for the
development of appropriate software.
ii) Email services between CSU, SSU, DSU and
laboratories and other stakeholders
E-mail services between CSU, SSU and DSU are
established but need to stabilize. The laboratories and
other stakeholders (medical colleges) are yet have
similar facilities.
iii) Rapid dissemination of health alerts to public,
health staff and civil societies
Rapid dissemination of health alerts to public
health staff and civil societies is being developed,
through 24X7 call service center (1075).
Videoconferencing facilities are established in state
headquarters and the CSU is interacting with states
periodically. Converting state units as teaching ends is
under consideration.
iv) Quality assurance surveys of laboratory
information
The mechanisms of quality assurance and control
of laboratory information is being developed.
Improve laboratory Support:
Currently, laboratory capacity in India for
diagnosis of infectious diseases is fragmented with
some capacity at the National Institutes of
Communicable Diseases, at the Indian Council for
Medical Research and at Medical Colleges around the
country. Presently, laboratory services exist in a
number of categorical programs with limited
coordination and, compounding the problem, there is
no apparent perceived need for coordination or
leadership at the national level.
There is no focal point within this mixture of
laboratories to ensure services are available where
needed and assure quality of testing. For example, there
is no place that assures quality of rapid diagnostic kits
purchased within the country. As would be expected
in a country of great diversity, there is also great
diversity of capability and capacity in laboratory
services. States like Maharashtra and Karnataka have
capability and have already embarked on building
laboratory capacity for IDSP. Where laboratory services
exist, there is a need to improve quality and to address
fundamental problems in the system related to
procurement and subsequent distribution of supplies.
In general, limited testing should be offered at the
district level. Peripheral health centers and sub-centers
are often performing microscopy (AFB and malaria)
should be left at that level. At the district level, testing
of human specimens should be limited to those tests
for which high quality rapid assays are available (e.g.,
dengue, leptospirosis). Presently, culture should be
limited to those laboratories designated as “state”
laboratories or facilities where there is a very clear
demonstration of sufficient volume of specimens to
retain the necessary skills. A process for quality
assurance needs to be established at each site identified
for laboratory strengthening.
1. The upgrading of laboratories at the state and
district level to improve laboratory support for
providing on time and reliable confirmation of
suspected cases, monitoring drug resistance
2. The introduction of quality assurance system for
laboratories:
3. Establishing External Quality Assurance System
(EQAS):
IDSP had envisaged 4 levels of laboratories namely:
L1 = Peripheral laboratories that will have
diagnostic facilities for Malaria, TB, Typhoid and
chlorination of well water and fecal contamination of
water, L2= District Public health laboratories will carry
out tests for Malaria, TB, Typhoid and chlorination of
well water and fecal contamination of water primarily
to confirm results from L1, and for quality control. They
would also have oversight responsibility of L1
laboratories. L3= Regional/State laboratories will carry
out all tests to confirm L1 and L2 results and for some
state specific diseases (e.g. Leptospirosis, KFD, Anthrax
etc). They would also have culture facilities for bacteria
and viruses along with drug sensitivity studies. L4=
Central and L4 reference laboratories for routine work
and specific outbreak investigations.
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Based on three years’ experience and challenges
in establishing the Public Health laboratories it is now
agreed that under IDSP apart from state Public Health
Laboratories and specialized laboratories (L3&L4) only
50 District laboratories (2 per focus state and 1 in rest
of the states each)will be strengthened to take up Public
Health laboratories responsibilities. Revised laboratory
strengthening plan of action under IDSP is addressing
the regional and referral laboratories. In the first phase,
states used the money for renovating and minor
additions to physical structure of all laboratories in the
districts. It was observed that most of the money was
distributed (based on average per unit) without
considering the needs of individual laboratories.
Vertical programs like NVBDCP and NTCP had
supported L1 laboratories up gradation in entire
country in last few years. Therefore from 2006 no
money is released for renovation unless a definite need
is ascertained.
Training for Disease Surveillance and Action:
The project aims to train both in formal and
informal sector for disease surveillance, specific training
for disease control, and special training of state/district
surveillance officers in epidemiology and specialized
training in laboratory work, data management and
communications.
In addition to the routine program trainings as
listed above, the training under IDSP has to cater to
larger need of epidemiologists and Microbiologists able
to organize and oversee IDSP activities at state and
district level. This would involve training epidemiologist
and microbiologists and rapid response team members
at the SSU and DSU. Two weeks Field Epidemiology
training has been field tested in 2007. It is decided to
train the Microbiologist and a lab. technician from each
of the 50 identified laboratories in quality assurance
and specific disease tests. The challenge now is to take
to scale both the training.
With GOI sanctioning of 766 posts of
epidemiologists, Microbiologists and Entomologists, on
one side there is good opportunity for public health
qualified professionals, on the other it is going to
become a challenge. NICD need to identify some more
regional institutions to take up 2 weeks field
epidemiology training in addition to the training of
trainers (TOTs) they are already handling.
Way Forward:
Infrastructure strengthening: Despite recent
improvements, obtaining information regularly from
the larger public hospitals and private sector from the
urban areas still remains a challenge for the IDSP. The
initiative started to rationalize the weekly reporting
forms needs to be implemented to reduce the burden
of nonspecific conditions on the surveillance system.
More importantly, the ability to analyze and act on the
information being generated is critically lacking
especially at the district level. Frequent turn-over of
state and district surveillance officers also slowed down
the effective implementation of surveillance activities.
To address this, a specialized cadre of epidemiologists
- which was not originally envisaged under the project
- has been strongly recommended by the Bank as well
as Centre for Disease Control (CDC) teams that recently
reviewed the project. Similarly, due to limited
availability of microbiologists, the original plan for
laboratory strengthening has been revised focusing
on making 50 public health laboratories functional and
link each district to such labs. The GOI has created
positions of epidemiologists, Microbiologist and
entomologists under the National Rural Health Mission
(NRHM). The challenge is to fill in these posts urgently
with motivated people and arrange for their induction
training with necessary field epidemiology and
microbiology training. Scaling down the laboratory
strengthening component to make 50 public health
laboratories functional during the next 6 months
appears to be doable task. Piloting of disease
surveillance in 4 metro cities needs acceleration to
provide lessons for scaling-up urban surveillance in
other cities.
I. Outbreak response:
1. The enhanced reporting and investigation of
outbreaks by IDSP is an important
accomplishment of the project, and warrants
recognition. However it will be important to
further strengthen IDSP capacity for early
outbreak detection by emphasis on prompt
outbreak reporting to the district surveillance
officer. Special emphasis is required on seeking
such information from the health providers and
different options such as giving mobile telephones
to the sub center (SC) reporting units should be
explored.
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
2. In addition to enhancing detection and prompt
reporting of outbreaks, determining the quality
of outbreak investigations should be an essential
evaluation component of the project. This will
require expanded and standardized recording of
information about outbreaks investigated: the
number of cases and deaths, causative agent,
timeliness of detection and response, results of
systematic investigation, including epidemiologic
characterization and determination of source(s),
and public health response. In some states, it will
also be important to improve coordination
between IDSP and epidemiology cells/response
units.
3. IDSP should invest substantial efforts to assure
the proposed Call Center is effectively
implemented. This will require strategic marketing
of the system to the providers and health
personnel in the area covered by the call center.
It will also require links to SSU (DSU) for promptly
evaluating the information, and giving feedback
to the provider (e.g. expedited access to reference
diagnostic tests, information about clinical
presentation of rare conditions, access to limited
therapy—e.g. diphtheria anti-toxin) and initiating
appropriate actions. Information from calls
should be routed simultaneously, not sequentially,
to relevant SSU (for follow-up) and CSU (for
information and to recognize cross-state
outbreaks).
4. Media scanning can detect possible outbreaks,
as well as identify rumors which need addressing.
Although it can be the responsibility of an SSU to
systematically monitor local newspapers, web
pages, etc, media scanning can also be done by
a contracted service. The benefit of a contracted
service is systematic, prompt scanning which is
not contingent on public health personnel; also,
any items noticed can be routed immediately to
the appropriate (and possibly multiple) district,
state, or national units.
II. Conditions to be reported under IDSP
1. IDSP should continue to refine strategies for
improving the interpretability of data by
emphasizing a) reporting units/data sources most
likely to provide usable and important
information, b) enhancing specificity of case
definitions, c) encouraging laboratory confirm-
ation and laboratory reporting and d)
encouraging consistency in reporting
2. Continued collection of S form data from sub-
centers reinforces community engagement with
IDSP so that outbreaks at the village level will be
recognized and reported through IDSP reporting
channels; for a single SC data collection burden
is not too high, and the proposed revision of S
form to eliminate age and sex breakdown of cases
will further minimize burden.
3. However, other reporting units (PHC’s, hospitals,
private hospitals, medical colleges, ID hospitals)
should report a revised list of conditions using
more specific case definitions. Revision of P form
may consider dropping non-specific and high
volume conditions e.g. fever, ARI Acute
Gastroenteritis (leaving cholera) etc. as they create
a large burden of data collection on the system,
but the data are difficult if not impossible to
interpret.
III. Strengthen laboratory diagnosis of
cases 1
1. Doctors in Hospitals with large load of outpatients
do not generally demand for investigations to
arrive at a diagnosis. The states need to promote
utilization of existing laboratory investigations
routinely and also make efforts to improve
diagnostic capabilities in these facilities.
2. Routine specimen transportation (from outbreaks
and hospitals) to the laboratories both in public
and private sector system (especially L3, L4 and
L5) needs streamlining.
3. Keeping vigilance on the quality of investigations
in these laboratories by external quality assurance
mechanism is equally important.
4. Promote reporting of laboratory confirmed data
using laboratory investigations reporting forms (L-
to L5 forms). Line listing of cases with positive
laboratory tests, and adding a column for type of
specimen {a cerebrospinal fluid (CSF) or blood
culture result is quite different from sputum} will
improve the utilization. IDSP should consider
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
collecting reports of positive tests for Hib,
rotavirus, pneumococcus, and other salmonella
species.
5. At the present, linkage of reports from clinical and
laboratory sources is not feasible (outside of the
individual patient record), so one may need to
accept some degree of duplication in order to
have information on the number of laboratory
confirmed cases.
IV. Sentinel Reporting Units
1. Continue to implement initiatives such as urban
surveillance and sentinel ID hospitals to target
large and strategically located hospitals for special
attention as reporting units. These sources are
likely to draw more severely ill patients from a
large population, thus efficiently providing
“sentinel” information about a large area. In
addition, they are likely to have, or can be
supported to have, better laboratory and clinical
diagnostic facilities.
2. Targeting reporting units such as strategic hospitals
and laboratories is a reasonable priority in all sites,
but it may be particularly important in states that
are less advanced in their IDSP activities, so that
at least some surveillance information is available
for these areas.
V. Rapid completion of the network (both for
data transmission and for video-
conferencing) is urgently needed; getting the
districts operational will be critical to realize the
full impact for IDSP. Videoconferencing should
be viewed as an “essential public health tool” for
surveillance and for outbreak management. Once
the system is operational at districts, there will be
even greater opportunities for frequent
communication without difficult travel.
References:
1. Integrated Diseases Surveillance Project, Project
Implementation Plan 2004-09, GOI, MOH &FW
(Department of Health) Nirman Bhavan New
Delhi 110001.
2. Project appraisal Document, June 7 2004 The
World Bank, New Delhi-11003
3. Integrated Disease Surveillance Program Annual
report- NICD 2007
4. Integrated Disease Surveillance Program Annual
report- Commissioner HFW&ME Gujarat 2007
5. IDSP Aid Memoirs, the World Bank, New Delhi
November 2006 & May 2007.
6. IDSP Mid-Term Evaluation, the World Bank, New
Delhi November 2007.
Suresh K: Integrated Disease Suveillance Project
Indian Public Health Association
Headquarter Secretariate
110, Chittaranjan Avenue, Kolkata-700073
Registration under Society Act No. S/2809 of 1957-58
Notice for 53rd Annual General Body Meeting
The 53rd Annual general Body Meeting of the IPHA will be held on 9th January, 2009 at 6 PM at
Kuvempu Kalakshetra Auditorium, KIMS Hospital Campus, K.R.Road, V.Puram,
Bangalore - 560 004. (Please reconfirm the exact venue and time from the organizers of the conference).
Sd/-
Dr. Madhumita Dobe
Secretary General, IPHA
144
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
World is in the stage of epidemiological transition
and the non-communicable diseases are overtaking
the communicable diseases. This phenomenon is not
only seen in developed countries but is also evident in
the developing countries like India. Among the major
non-communicable diseases, cardiovascular diseases
are recognized as major public health problems by
WHO1. Though several studies have been carried out
among the workers with sedentary lifestyle to assess
the risk factors for NCD, but very few studies have
been carried out among labour population especially
in India. One argument towards this can be non
exposure to risk factors like decreased physical activity
and obesity among the labourers by virtue of their
occupation but other side of the coin suggests that the
risk factors like smoking and alcohol consumption is
increasing among the lower socio-economic strata.
With this background the present study was carried
out to find out the prevalence of hypertension as well
as different cardiovascular risk factors and to assess
association of different risk factors with hypertension
if any.
The present cross-sectional study was carried out
in 2005 among the labourers of different tribes of
Chhotaudepur region of Gujarat. The selected villages
have about 30,000 tribal population; mostly being
engaged in labour work. From the sampling frame of
labour population aged 20 years and above, 154 study
Short Communication
Hypertension and Epidemiological Factors among
Tribal Labour Population in Gujarat
*Rajnarayan R Tiwari1
1Scientist C, Occupational Medicine Division, National Institute of Occupational Health, Ahmedabad, Gujarat.
*Corresponding author: rajtiwari2810@yahoo.co.in.
Summary
A cross sectional study was carried out in 2005 to find out the magnitude of hypertension among
154 tribal labourers of Gujarat belonging to Naika, Rathwa and Damor tribes. WHO classification
of hypertension was taken as operational criteria and data was collected in pre-designed, pre-
tested schedule. Blood pressure measurement was done twice on each subject using mercury
sphygmomanometer. Overall magnitude of hypertension was found to be 16.9%, and only
smoking was found to have significantly associated with it.
subjects were included by simple sampling random
technique in the present study. Pre-designed, pre-tested
schedule was used to collect data regarding
demographic characteristics and different risk factors
like smoking and alcohol. For the present study all those
who have smoked at least one cigarette or bidi in the
last one-month period were considered as current
smoker while those who have left smoking since ≥1
year were considered as ex-smokers. For the purpose
of ever smokers the current smokers and ex-smokers
were added together. Similarly those who reported to
have taken alcohol at least once in last one month
were considered as current alcohol users. This was
followed by measurement of blood pressure, height
and weight.
Two blood pressure readings were obtained on
left arm after the subject had rested for at least 5
minutes in a seated position using mercury sphygmo-
manometer, 10 minutes apart. Finally average of two
readings was taken. SBP ≥ 140 mm Hg and/or DBP ≥
90 mm Hg and/or treatment with anti-hypertensive
medication were labeled as hypertensive2. Subjects
having hypertension were refereed to the Primary
Health Centre of Chhotaudepur for further
management. Body weight was measured on the
weighing scale, wearing minimum outerwear (as
culturally appropriate) and without any footwear.
Height was measured using a non-stretchable tape with
145
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
the subject in an erect position against a vertical surface,
with the head positioned so that the top of the external
auditory meatus was level with the inferior margin of
the bony orbit. Body mass index was calculated by
dividing the weight in kilograms with the square of
height measured in meters. WHO classification of
obesity was used for the categorization3. Percentages
were calculated and chi-square test was done using
Epi Info software.
Out of 154 subjects, 59.1% were male while
40.9% were female. Majority of the study subjects
belonged to less than 25 years of age. Overall
magnitude of hypertension was found to be 16.9%.
38.5% of the subjects were ever smokers while only
5.5% have taken alcohol. Only 9 (5.4%) subjects were
overweight-pre-obese. The mean BMI for the females
was found to be 19.3 ± 3.5 kg/m2. The distribution of
hypertension according to the risk factors is shown in
Table 1. Except for smoking all other factors were found
to be non-significant.
In the present study the overall magnitude of
hypertension was found to be 16.9%.
However a study among tribal
“Oraon” population of Orissa revealed
lower prevalence of hypertension (4.6/1000
population)4. Similar finding (prevalence
5.8%) was also noted by Chadha SL et al5
among Gujaratis residing in Delhi. In
contrast a study among primitive tribes of
Orissa reported prevalence of hypertension
among males and females as 31.8% and
42.2%, respectively6. Recent studies have
shown that Asian Indians are particularly
susceptible to non-communicable diseases.
Comparison with studies shows that there
is a clear increase in magnitude of
hypertension in urban Indians from 6.2%
in 1970 to 26.9% in 20007, 8. This can be
attributed to the epidemiological transition
and changing lifestyles.
Although the magnitude of
hypertension is age related, being highest
in those over 50 years of age9,10, but the
non-significant association of age with
hypertension in present study can be
attributed to comparatively young age
group of study population; mean age being 31.7±10.1
years. All the hypertensive subjects were non-obese
and this could be due to very low magnitude of obese
in the study population. However the mean BMI of
the females was similar to that reported in NFHS survey
data while the proportion of those females having
BMI<18.5 kg/m2 was found to be 38.1% which was
lower than 47.7% as reported in NFHS survey.
Magnitude of smoking is higher in this study and
smoking has been found a significant factor for the
occurrence of hypertension. There is a plethora of
studies suggesting the tobacco smoking as an important
and independent risk factor for hypertension and
cardiovascular diseases11.
Thus to summarize, this study reveals that the
magnitude of hypertension in the tribal labour workers
is comparable to the magnitude found in the other
Indian studies. It is likely that a systematic and larger
study may give better understanding of the prevalence
and the underlying risk factors among these workers.
Table 1: Distribution of hypertension according to
different risk factors
Risk Factors Number Hypertensives χ2;df, p-value
No (%)
Age (in years)
<45 132 23 (17.4)
≥45 22 3 (13.6) 0.017; 1; >0.05
Sex
Male 91 15 (16.5)
Female 63 11 (17.5) 0.025,1, >0.05
Smoking history
*Ever smokers 35 9 (25.7)
Never Smokers 56 6 (10.7) 3.52; 1; <0.05
Alcohol use
*Present 5 1 (20.0)
Absent 86 13 (15.1) 0.407; 1;>0.05
Body mass index
Overweight-pre-obese 9 -
Non-obese 145 26 (17.9) -
* Included only males
Tiwari RR: Hypertension among Tribal Labour Population
146
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
References:
1. Integrated NCD management and prevention. In
the official website of WHO. http:// www.who.int
2. WHO. Epidemiology and prevention of
Cardiovascular diseases in elderly people. WHO
Technical Report Series No. 853, World Health
Organization, Geneva, 1995.
3. WHO. Obesity: Preventing and managing the
global epidemic. WHO Technical Report Series
No. 894, World Health Organization, Geneva,
2000.
4. Dash SC, Sundaram KR, Swain PK. Blood
pressure profile, urinary sodium and body weight
in the ‘Oraon’ rural and urban tribal community.
J Assoc Physicians India. 1994; 42: 878-80.
5. Chadha SL, Gopinath N, Ramachandran K.
Epidemiological study of coronary heart disease
in Gujaratis in Delhi (India). Ind J Med Res 1992,
96:115-121.
6. Kerketta AS, Bulliyya G, Babu BV, Mohapatra
SS, Nayak RN. Health status of the elderly
population among four primitive tribes of Orissa,
India: A clinico-epidemiological study. Zeitschrift
für Gerontologie und Geriatrie. Published online
on 10 April 2008. http://www.springerlink.com/
content/6g424u36581868wq/ last visited on 10th
July 2008.
7. Malhotra SL. Studies in arterial blood pressure
in the North and South India with reference to
dietary factors in its causation. J Assoc Physicians
India 1971; 19:211-224.
8. Chadha SL, Radhakrishnan S, Ramachandran K,
Kaul U, Gopinath N. Epidemiological study of
coronary heart disease in urban population of
Delhi. Indian J Med Res 1990; 92: 424-30.
9. Anand MP. Epidemiology of hypertension. In:
Anand MP, Billimoria AR, editors. Hypertension:
an international monograph. New Delhi. Indian
J Clin Practice 2001:10-25.
10. Singh RB, Suh IL, Singh VP et al. Hypertension
and stroke in Asia: prevalence, control and
strategies in developing countries for prevention.
J Hum Hypertens 2000; 14: 749-763.
11. Noel H. Essential hypertension: evaluation and
treatment. J Am Acad Nurse Pract 1994; 6: 421-
435.
Tiwari RR: Hypertension among Tribal Labour Population
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147
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Street sweepers are exposed to significantly more
amount of dust, microorganisms, toxins and vehicle
exhaust than the recommended norms1-3. Due to this
occupational exposure they are very much vulnerable
to develop the chronic diseases of respiratory system
such as chronic bronchitis, asthma, etc. The problem
is further compounded by various socioeconomic
factors like habit of smoking, poor housing conditions,
etc4-8. Therefore a need was felt to study the proportion
of chronic respiratory morbidity and the role of various
risk factors contributing to chronic respiratory morbidity
in this occupational group.
The present study was designed as a cross-
sectional study with a comparison group. The study
group comprised of all the street sweepers working in
Hanumannagar Zone of Nagpur Municipal
Corporation (N=273). The comparison group included
all the class IV workers working in the office buildings
of Nagpur Municipal Corporation, Nagpur (N =142).
The study was undertaken during November 2003 to
Short communication
Respiratory Morbidity among Street Sweepers Working at
Hanumannagar Zone of Nagpur Municipal Corporation,
Maharashtra
*Sabde Yogesh D1, Sanjay P Zodpey1
1Department of Preventive and Social Medicine, Government Medical College and Hospital, Nagpur, Maharashtra,
India. Corresponding author: ysabde@yahoo.com
January 2005.
Pretested proforma was used to record the
necessary information such as socio-demographic
factors, occupational history, past and present medical
history & findings of clinical examination. Standard
clinical methods were used and opinion was sought
from specialists of Government Medical College
Nagpur to confirm the diagnosis.
International Classification of Diseases version 10
(ICD 10) was used to make the final diagnoses e.g.
Chronic bronchitis (ICD No. J44) defined as presence
of a chronic productive cough on most of the days for
three months, in each of the two successive years, in
patient in whom other causes of chronic cough have
been excluded (Other causes of chronic cough were
excluded by sputum microscopy and chest X-ray).
As occupational exposure to dust is known to
cause chronic respiratory morbidity like chronic
bronchitis, bronchial asthma and bronchiectasis, the
Summary
Due to the occupational exposure street sweepers are very much vulnerable to develop the chronic
diseases of respiratory system. Therefore this study was undertaken to find out the proportion
of chronic respiratory morbidity among the street sweepers and the role of various associated
risk factors. The study included two groups: study group i.e. street sweepers and comparison
group (Class IV workers working in the office buildings). Various risk factors studied were age,
sex, socioeconomic status, length of service, smoking habit, type of house, area of residence,
cooking fuel and pets. Proportion of chronic respiratory morbidity (chronic bronchitis, asthma
and bronchiectasis) was higher (8.1%) among street sweepers compared to comparison group
(2.1%), the difference being statistically significant. Unconditional multivariate logistic regression
revealed that risk of having chronic respiratory morbidity among street sweepers was 4.24 (95 %
CI of OR = 1.24 to 14.50) times higher than that in the comparison group and the risk increased
significantly with increasing length of service (OR = 1.75, 95 % CI = 1.09 to 2.81).
148
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
effect of various risk factors on the occurrence of
chronic respiratory morbidity was studied in detail.
Bivariate analysis was initially done to study the
effect of various risk factors associated with respiratory
morbidity, viz. age, sex, socioeconomic status,
occupation, length of service, smoking habit, house,
area of residence, cooking fuel and pets. The chi-square
(χ2) test was applied to test the significance. In the
second step, unconditional multiple
logistic regression (MLR) analysis was
carried out to estimate the adjusted odds
ratios (OR) for the abovementioned risk
factors for chronic respiratory morbidity.
The Full Model of MLR comprised of all
the risk factors included in the study. Of
these, the factors significant at α = 0.25
were identified and included in the Final
Model 1. The factors which were
significant in Final Model 1 at α = 0.05
were then included in Final Model 2 and
again tested at α = 0.05. The factors
thus identified were considered to be the
significant risk factors. STATA version 8
was used for the analysis of the data.
There were a total of 273 street
sweepers working in Hanumannagar
Zone of Nagpur Municipal Corporation,
Nagpur and 142 class IV employees
(comparison group) working in office
buildings of Nagpur Municipal
Corporation, Nagpur. All of them
participated in the study.
Table 1 shows the distribution
of various respiratory morbid
conditions among the subjects. It
was observed that the proportion
of chronic bronchitis was
significantly more (p = 0.0346)
among street sweepers (5.9%) as
compared to the comparison
group (1.4%). The other chronic
respiratory morbidity included
bronchial asthma and
bronchiectasis. While considering
chronic respiratory morbidity
collectively, it was found that the
proportion was more among street
sweepers (8.1%) than the comparison group (2.1%),
the difference being significant statistically (p =
0.0157).
None of the 273 street sweepers was using protective
devices like masks, goggles, etc. while working.
Proportion of chronic respiratory morbidity
increased with increase in age and length of service.
This increase was statistically significant when chi
Table 1: Distribution of respiratory morbid conditions
among the study subjects
ICD code Morbid Street Comparison
Conditions sweepers group P value
(n=273) (n=142)
No. (%) No. (%)
J41 Chronic bronchitis 16 (5.9) 2 (1.4) 0.0346*
J45 Bronchial asthma 5 (1.8) 1 (0.7) 0.3613
J00 URI 20 (7.3) 10 (7) 0.9156
J49 Bronchiectasis 1 (0.4) 0 0.5214
* Statistically significant
Table 2: Distribution of chronic respiratory morbidity
according to age and length of service
Street sweepers Comparison group
(n=273) (n=142)
Subjects Morbidity Subjects Morbidity
No. (%) No (%)
Age group (years)
20 - 29 19 0 13 0
30 - 39 104 6 (5.8) 35 1 (2.9)
40 - 49 114 11 (9.6) 69 2 (2.9)
≥50 36 5 (13.9) 25 0
Length of Service (years)
0-9 80 3 (3.8) 42 0
10 - 19 103 7 (6.8) 48 1 (2.1)
20 - 29 78 11 (14.1) 45 2 (4.4)
≥30 12 1 (8.3) 7 0
χ2 test for linear trend p < 0.05
Sabde YD et al: Respiratory Morbidity among Street Sweepers at Nagpur
149
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
square test for linear trend was applied (p<0.05) (Table
2).
In full model of unconditional multiple logistic
regression analysis (MLR), it was found that the
occupation as street sweeper was significantly
associated with the proportion of chronic respiratory
morbidity (p = 0.019). None of the other hypothesized
risk factors were found to be significant at α (level of
significance) = 0.05. However to include the marginally
significant risk factors in the final reduced model, we
identified the risk factors having p value less than 0.25
in full model of MLR. These factors were lower
socioeconomic status (p = 0.204), occupation as street
sweeper (p = 0.019), increasing length of service (p =
0.156), and smoking habit (p= 0.152).
In the final model of multiple logistic regression
analysis it was observed that the p value was significant
for two factors viz. occupation as street sweeper (p =
0.021) and increasing length of service (p = 0.021).
The Odds Ratio for occupation as street sweeper was
4.24 (95% CI = 1.24 to 14.50) and that for increasing
length of service was 1.75 (95% CI = 1.09 to 2.81).
Thus the findings of the present study revealed
that the proportion of chronic respiratory morbidity
(chronic bronchitis, bronchial asthma and
bronchiectasis) was significantly higher among street
sweepers than the comparison group subjects. The
higher proportion of chronic respiratory morbidity
among the street sweepers having longer length of their
service as a street sweeper could be because of the
increasing duration of occupational exposure. These
results indicated a duration response relationship
between the occupational exposure and the outcome
as chronic respiratory morbidity. These findings were
supported by the fact that none of the street sweepers
used masks during sweeping.
These findings were in agreement with the study
conducted among Danish Waste Collectors, where the
proportion of chronic bronchitis (7.8%) was
significantly more than that among park workers4.
Raaschou-Nielsen O et al also found a significantly
higher proportion of chronic bronchitis and asthma in
Copenhagen Street Cleaners compared with Cemetery
Workers5. Nagraj C et al at Bangalore7 and Diggikar
UA at Pune8 also detected higher proportion of
respiratory morbidities among the street sweepers.
Thus it is recommended to use protective devices
for these street workers to ward off respiratory
morbidity.
References:
1. Krajewski JA, Tarkowski S, Cyprowski M,
Szarapinska-Kwaszewska J, Dudkiewicz B.
Occupational exposure to organic dust associated
with municipal waste collection and management.
Int J Occup Med Environ Health 2002; 15(3):289-
301.
2. Heederik D, Douwes J. Towards an occupational
exposure limit for endotoxins. Ann Agric Environ
Med 1997;4:17–19
3. Wilkins K. Gaseous organic emissions from
various types of household waste. Ann Agric
Environ Med 1997; 4:87–89.
4. Hansen J, Ivens UI, Breum NO, Nielsen M, Würtz
H, Poulsen OM et al. Respiratory symptoms
among Danish waste collectors. Ann Agric
Environ Med 1997; 4: 69–74.
5. Raaschou-Nielsen O, Nielsen ML, Gehl J. Traffic-
related air pollution: exposure and health effects
in Copenhagen street cleaners and cemetery
workers. Arch Environ Health 1995; 50(3):207-
13.
6. Meer G, Kerkhof M, Kromhout H, Schouten JP,
and Heederik D. Interaction of atopy and smoking
on respiratory effects of occupational dust
exposure: a general population-based study.
Environ Health 2004; 3:6.
7. Nagaraj C, Shivram C, Jayanthkumar K, Murthy
NNS. A study of morbidity and mortality profile
of sweepers working under Banglore City
Corporation. Ind J of Occup and Environ Med
2004; 8(2):11-16.
8. Diggikar UA. Health status of street sweepers with
reference to lung function tests [Dissertation].
Pune University; 2004.
Sabde YD et al: Respiratory Morbidity among Street Sweepers at Nagpur
150
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
The health care workers who deal with patients,
especially who are exposed to blood, body fluids and
potentially contaminated instruments or wastes, are at
high risk of contracting serious blood-borne infections
like hepatitis B (HBV) , hepatitis C (HCV) and HIV
through occupational injuries during their professional
activities1 - 5. Percutaneous injury is the most common
method of exposure to blood borne pathogens6. In
the USA approximately 6,00,000 to 8,00,000 needle
stick injuries occur annually among the health care
workers, and as a result more than 1000 of them
contract hepatitis C or HIV. The most affected category
of health care workers is the nurses who are involved
in 42% to 74% of the reported needlestick injuries1.
This hospital-based retrospective study was
conducted among the nurses involved in patient care
to quantify the incidence and risk of needle stick injuries
during patient care in the hospital setting and to asses
certain aspects of their practice profiles during and after
such events. The study places were North Bengal
Medical College & Hospital, located in a rural area of
Darjeeling district and the city-based N.R.S. Medical
College & Hospital, Kolkata, West Bengal. The study
period was from May 2004 to April 2005. Upon
Short Communication
Needle Sticks Injury among Nurses Involved in Patient Care:
A study in Two Medical College Hospitals of West Bengal
*G. K. Joardar1, C. Chatterjee2, S.K.Sadhukhan3, M.Chakraborty4, P. Das5, A.Mandal6
Summary
A hospital-based retrospective study on a sample of 228 nurses involved in patient care, in two
medical college hospitals of West Bengal, showed that 61.4% of them sustained at least one Needle
Stick Injury (NSI) in last 12 months. The risk of such injuries per 1000 nurses per year was found
to be 3,280. Out of the most recent injuries among 140 nurses, 92.9% remained unreported to
appropriate authorities; in 52.9% events hand gloves were worn by the nurses; only 5% of those
nurses received hepatitis B vaccine, 2.1% hepatitis B immunoglobulin and none of them received
post exposure prophylaxis for HIV.
approval by the administration and getting lists of total
725 such nurses from the nurses’ authorities, one-third
of the nurse population was selected for the study. With
a random start, every third subject from the list was
selected by systematic random sampling technique.
Thus a total of 228 nurses comprised the sample size.
The inclusion criterion was to work in hospital setting
uninterruptedly for last 12 months.
After review of literatures on similar studies and
getting inputs from experts in epidemiological studies
the draft questionnaire was prepared. The final
questionnaire for data collection was prepared after
the draft questionnaire was pre-tested among the
student nurses. The nurses themselves reported data
on their experience in the last 12 months period. In
case of multiple injuries, the detail information about
the most recent injury was elicited. The anonymity of
the respondents was ensured. The data analysis was
done using suitable descriptive statistics (rates, ratio
and proportion). The risk of needle stick injury per
1000 nurses per year was calculated as follows: The
cumulative incidence of needlestick injuries among all
nurses in last 12 months ÷ total number of nurses
studied x 1000.
1Associate Professor, 5Assistant Professor, Community Medicine, 6Principal, NRS Medical College, 2Assistant
Professor, Community Medicine, Medical College, Kolkata, 3Assistant Professor, MCH, All India Institute of Hygiene &
Public Health, Kolkata, 4Professor, Community Medicine, North Bengal Medical College, Darjeeling.
*Corresponding author: gkjoardar@rediffmail.com.
151
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Regarding specific protection against hepatitis B
infection, it was observed that only 21.1% (n=48) of
the nurses were fully immunized with hepatitis B
vaccine. Out of the total 228 nurses studied, 61.4%
(140) experienced at least one needle stick injury in
the last 12 months. The frequency distribution of the
injuries showed that 21.1%, 15.8%, 9.6%, 9.2% and
5.7% of those nurses sustained 1-3, 4-6, 7-9, 10-12
and 13 to ≥ 15 injuries, respectively, in the last 12
months. The cumulative incidence of the needle injury
events during the last 12 months was 748; and the risk
of NSI per 1000 nurses per year came to 3,280.
Table no. 1 shows that out of 140 most recent
injuries all were puncture in nature and 84.3% of them
drew blood; 53.6% were associated with disposable
needle & syringe devices; 20.7% were associated with
reusable needles and 25.7% with suture needles. It
was revealed that 92.3% of those injuries were not
reported to the appropriate authorities. Regarding the
reasons of non-reporting, it was revealed that in more
than half of the events the nurses had not enough time;
and in almost one-third of the events they were
unaware of the reporting procedure.
Regarding certain aspects of their practice profiles
it was observed that out of those 140 nurses (with
their recent injuries), 52.9% had worn gloves in their
hands during the procedures involved; 92.1% had their
hands washed with soap and water after the events;
only 5% of them received hepatitis-B vaccine and 2.1%
hepatitis-B immunoglobulin. Regarding post-injury
laboratory testing, as far as the knowledge of the injured
nurses, only 5.7% of the source patients were tested
for both HIV and hepatitis-B, and none for hepatitis-
C. Only 3.6% of those nurses were tested for hepatitis-
B and two were tested positive (HBsAg +ve); 2.1%
for HIV - all of them found non-reactive; and none
were tested for hepatitis-C. The injured nurses had no
knowledge regarding the test results of the source
patients.
Similar studies in different areas of the world
showed variations in the proportions of health care
workers sustaining needle stick injuries during patient
care in the hospital settings. A study in the USA showed
that at least one needle stick injury occurred among
27.5% nurses in last one year1. A study in three tertiary
care hospitals in south India showed that 75% of the
health care workers sustained at least one injury in
last 12 months7. Chaudhary and Agarwal from
Lucknow (India) observed that 53% of health care
workers experienced at least one injury within 0 - 6
years period 8. Regarding the risk of needlestick injuries
per 1000 nurse per year, the present study observed
much higher value of 3280 compared to 448 as
observed by Jennifer M. Lee et al1.
Compared to 92% non-reporting of injuries (to
appropriate authorities), 70% to 78% non-reporting
were observed among nurses in the USA, where
reporting of all such events is a national mandate1.
Table 1: Profiles of the most recent
needle stick injuries and certain aspects
of practice among the nurses
experiencing the injuries (n=140)
Profile No. (%)
Character of injury
Puncture, drew blood 118 (84.3)
Puncture, did not draw blood 12 (15.7)
Devices involved
Disposable needles 75 (53.6)
Reusable needles 29 (20.7)
Suture Needles 36 (25.7)
Reporting of injuries
Reported 10 (7.1)
Not reported 130 (92.9)
Practice during the procedure
Used gloves 74 (52.9)
Hand washing after the injure
Washed hands with soap & water 129 (92.1)
Received post-exposure prophylaxis
Hepatitis B vaccine 7 (5.0)
Hepatitis B immunoglobulin 3 (2.1)
Anti Retroviral Therapy for HIV 0
Tests done on source patients
For HIV 8 (5.7)
For Hepatitis B 8 (5.7)
For Hepatitis C 0
Tests done on nurses themselves
For HIV 3 (2.1)
For Hepatitis B 5(3.6)
For Hepatitis C 0
Joardar GK et al: Needle Stick Injuries among Nurses
152
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
The source analysis in a study among 380 health care
workers who sustained needle stick injuries (in a tertiary
care hospital in Mumbai) observed that 6.1%, 3.9%
and 3.2% of the sources were positive for hepatitis-B,
HIV and hepatitis-C, respectively 6. A similar study,
among 38 health care workers in Mumbai observed
that 26.3% of the sources tested positive for HIV and
10.5% positive for hepatitis B 9. A study conducted in
Lucknow observed that out of the 79 health care
workers who sustained needle stick injuries, none
received post exposure prophylaxis (PEP) for HIV 8.
The nurses involved in patient care in the hospital
settings are at great risk of sustaining needle stick
injuries and acquiring dreaded blood borne infections
like HIV, hepatitis-B and hepatitis-C as a consequence
of their occupational exposures. There is lots of scope
in improving their awareness and practices as how to
minimize this risk and adverse consequences of such
injuries through appropriate IEC activities (including
in-service training), strict adherence to universal safety
precautions and universal immunization for them with
appropriate vaccine(s) like hepatitis-B vaccine.
Acknowledgement
The authors acknowledge their thankfulness to
authorities of North Bengal Medical College &
Hospital, Sushrutanagar, Darjeeling and N.R.S.
Medical College & Hospital, Kolkata for their support
and help
References:
1. Jennifer M. Lee, Marc F.Botteman, Lars
Nicklasson et al. Needle stick injury in acute care
nurses caring for patients with diabetes mellitus.
Current Medical Research & Opinion 2005; 21(5):
741-747.
2. Anthony S. Fauci, H. Clifford Lane. Human
Immunodeficiency Virus Disease: AIDS & Related
Disorders. Harrison’s Principles of Internal
Medicine; Mc Graw Hill, 2005; 16th edition:
1076-1139.
3. Reproductive & Child Health, Module for Medical
Officers (Primary Health Care) MO (PHC),
Integrated Skill Development Training, National
Institute of Health & Family Welfare, Munirka,
New Delhi. November, 2002: 489-516.
4. Park K. Park’s Text Book of Preventive & Social
Medicine; M/s Banarasidas Bhanot, Jabalpur
(India), 2005; 18th edition: 167 – 175 and 271 -
281.
5. Physician’s Guide, HIV/AIDS Prevention &
Awareness (2006); National AIDS Control
Organization, William J. Clinton Foundation HIV/
AIDS Initiative in association with Indian Medical
Association: 45-66 and 111-142.
6. Mehta A, Rodrigus C, Ghag S, Bavi P, Shenai S,
Dastur F. Needle stick injuries in a tertiary care
centre in Mumbai, India. Journal of Hospital
Infection 2003; 60 (4): 368-373.
7. Tetali S, Chaudhary P L. Occupational exposure
to sharps and splash: Risk among health care
providers in three tertiary care hospitals in south
India. Indian Journal of Occupational &
Environmental Medicine 2006; 10: 35-40.
8. Chaudhary R, Agarwal P. Prevalence of Needle
Stick injury (NSI) and its knowledge among health
care workers in a tertiary care hospital in north
India. Int Conf AIDS 2004 Jul 11-16; 15: abstract
no. ThPeC7488.
9. Rele M, Mathur M, turbadkar D. Risk of
needlestick injuries in health care workers – A
report. Indian Journal of Medical Microbiology
2002; 20 (4): 206-207.
Joardar GK et al: Needle Stick Injuries among Nurses
153
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
The equation for success in sports is complex.
Proper nutrition forms the foundation for physical
performance as it provides both the fuel for biologic
work and chemicals for extracting and using potential
energy contained within this fuel. Food also provides
essential elements for the synthesis of new tissues and
the repair of existing cells. Nutrition thus plays an
important role in attaining a high level of achievement
in sports. Importance of nutrition in sports should reach
all sports personnel to maximise their performance1.
In recent times there has been a great emphasis
on various aspects of nutrition for sportsmen but a very
little attention has been paid to sportswomen. This is
largely due to lack of opportunities for women in
athletic participation and lack of interest and expertise
in this area. The available research findings do not
provide adequate information regarding diet pattern
and nutritional profile of Indian sportspersons, and
especially of sportswomen. Moreover, there is paucity
of data on nutrition education interventions among
Indian sportsmen2.
With the Commonwealth Games in 2010 being
held in New Delhi, it is important to meet the gap in
nutrition research in sportswomen and formulate plans
for nutrition intervention.
Short Communication
Dietary Profile of Sportswomen Participating in
Team Games at State/National Level
*Ritu Jain1, S. Puri2, N. Saini3
1Research Nutritionist, Public Health Nutrition and Development Centre, 2Reader, Department of Foods and Nutrition,
Institute of Home Economics, University of Delhi; 3Senior Lecturer, Physical Education, Institute of Home Economics,
University of Delhi. *Corresponding author: jainritu84@gmail.com
Summary
A cross sectional study was conducted to assess dietary profile of 100 Delhi based national /
state level sportswomen, aged 18 – 25 years, participating in team games – volleyball, hockey,
football and kabaddi. Mean energy intake was found to be 1471 + 479 Kcal. Only 24 percent of
the sports women met the recommendations of 60 – 65 energy percent from carbohydrates and
87 percent were consuming more than 25 energy percent from fat. The mean macronutrients and
micronutrient intakes of all the subjects were much lower than the recommendations. Improper
food choices were also observed in majority. It becomes necessary to generate awareness among
sports personnel regarding proper nutrition practices.
In this perspective, the present study was
undertaken in an attempt to study the dietary profile
of sports women participating in team games at state
or national level.
We planned a cross-sectional descriptive study
during September 2006 to February 2007.
The sample consisted of 100 college sports
women participating in different team games – hockey,
football, volleyball and kabaddi at state or national
level. Players between 18-25 years of age, having
training period of atleast one year, playing at state or
national level, bonafide students of Delhi University
Colleges and willing to participate in the study were
purposively selected for ease in follow up from Sports
Authority of India training centers where camps and
practice sessions were organized on regular basis. A
pre-tested structured questionnaire was used to gather
information on lifestyle patterns, health status and
dietary habits. Dietary assessment was done using 24-
hour dietary recall and food frequency questionnaire.
The subjects were asked to report the food intake over
the past 24 hours, which included the foods consumed
as well as the quantity in household measures. The
household measures were then converted to raw food
amounts based on the values given by Raina et al3.
The energy, macronutrients and micronutrients
154
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
contents were then calculated based on Nutritive Value
of Indian foods4. Physical activity profile of the subjects
was studied by means of 24-hour activity record
method. The total daily energy expenditure was
calculated using Satyanarayan codes5 that involves
estimation of energy expenditure of 9 groups of
activities. 24-hour activity record and 24-hour dietary
recall were done for the same day to find out the energy
balance.
The data collected was subjected to qualitative
and quantitative analysis using a statistical package
for social sciences (SPSS, Version 9.0). Percentages
and frequencies of distribution were calculated for the
general information, lifestyle related information,
health profile and dietary patterns. The mean and
standard deviations were calculated for energy intakes
and intake of other nutrients.
Results
Of 100 subjects enrolled, 60 percent were national
level players. Even though participating in sports, 22
percent of the subjects did not perceive themselves as
fit. Around 60 percent of subjects skipped atleast one
of the meals and 40 percent subjects reported changes
in their menstrual cycle that could be due to arduous
exercise training.
Table 1 depicts the mean intakes of different
nutrients by the study sportswomen.
It was observed that the mean energy, protein,
fat, carbohydrate and micronutrients intakes of all the
respondents were found to be much lower when
compared with NIN recommendation 6. Mean vitamin
C and calcium intakes of majority of subjects were
higher than the ICMR7 recommendations for normal
adult female but were lower than the values given by
Rao8 for Indian sports people.
We tried to further categorize the intakes into the
levels of macronutrient adequacy. It was found that
74 percent subjects met the protein recommendations
of 10 – 15 energy percent. For 15% subjects protein
constituted >15 energy percent and the rest (11%) <
10 energy percent. However, only 24 percent of the
sports women met the recommendations of 60 – 65
energy percent from carbohydrates with 71 percent
consuming less than 60 energy percent from
carbohydrates. Correspondingly, 87 percent of the
respondents were consuming more than 25 energy
percent from fat, while only 7% subjects met the
recommendations of 20 – 25 energy percent from fat.
Data also revealed that 67 percent, 87 percent and 99
percent of the subjects had their intakes of thiamin,
riboflavin and niacin respectively lower than one-third
of recommended values.
Further analysis revealed that 95 percent of
subjects used to eat chapatti daily. Items like rice (57%),
paranthas (49%), biscuits (50%) and bread (43%) were
consumed frequently. Protein foods consumed
included pulses, animal foods and milk and milk
products like curd paneer etc. Pulses either whole or
washed constituted an integral part of their daily meal.
All subjects reported to be consuming vegetables and
fruits daily including a variety of these foods in their
menu i.e. green leafy vegetables (67%), root vegetables
(65%), other vegetables (62%) and seasonal fruits and
vegetables (72%). Ghee, butter and refined oil were
also used daily. Almost all the subjects took one or the
other beverage to rehydrate themselves after their
practice as well as competitions. Most frequently
consumed beverages by the subjects include tea/
coffee, juices and aerated drinks. 51 percent of the
respondents never took aerated drinks as they provide
only empty calories. 47 percent of the subjects never
took any sports drink for rehydration.
Energy expenditure for most of the players
exceeded their intake thus putting them into negative
energy balance.
Table 1: Mean intakes of various nutrients
by the sports women (n=100)
Nutrient Mean + SD (Range)
Energy (kcal) 1471 ± 479 (629-3429)
Protein (g) 46.1 ± 16.3 (15.9-114.4)
Fat (g) 50.8±20.4 (14.9-127.8)
Carbohydrate (g) 207.6±68.8 (82.9-455.7)
Calcium (g) 609.8±246.3 (166.2-1271.4)
Iron (mg) 10.1±3.9 (3.3-26.4)
Thiamin (mg) 1.13±0.43 (0.36-2.52)
Riboflavin (mg) 1.02±0.44 (0.20-2.49)
Niacin (mg) 8.28±3.28 (3.33-22.40)
Vitamin C (mg) 76.96±69.95 (7.20-326.05)
Vitamin A (mcg) 487.33±488.79 (72.28-1211.93)
Jain R et al: Dietary Profile of Sports Women
155
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
The findings revealed that many of the subjects
were initiated into sports in their early childhood even
though it may not be the same sport that they are
pursuing at present. Only 44 percent of the subjects
enrolled for the study have regular meals. In fact 20
percent of respondents had less than three meals a
day; 31 percent of them skipped breakfast. They
reported that these three meals included the
refreshment provided to them by the camp organizers.
It was found that the dietary energy was being
derived from fat rather than from carbohydrate as fried
snacks and namkeens was consumed frequently. Faulty
food choices, preference for junk foods could be the
reason and therefore counseling for proper food
choices at low cost becomes imperative.
Since most of the subjects have reported sub
optimal energy intakes, their menstrual irregularities
could be addressed if their energy intakes were
improved in the future as regular menstruation helps
to maintain bone mineral density9 and thus women
who do not menstruate regularly may have a higher
risk for the development of a stress fracture. Decreasing
the amount of training or increasing energy intake and
body weight restores regular menstrual cycles10.
Thus in order to maximize the physical
performance, it is imperative to develop information
booklets for these players to generate awareness
regarding proper nutrition practices. Information could
also be elaborated with special reference to the
particular game keeping cost factor in mind.
Acknowledgements
With a deep sense of gratitude, the author wishes
to express sincere thanks to lecturers in physical
education of the selected colleges, statistician and the
respondents for their cooperation in completion of the
work. The author is also grateful to Dr. Sheila Vir,
Director, Centre for Public Health Nutrition, New Delhi
for her encouragement and useful discussions during
the course of preparation of this paper.
References:
1. Meti R, Sarawathi G. Impact of nutrition
education and carbohydrate supplementation on
performance of high school football players. Ind
J Nutr Dietet 2002; 43: 197 – 206.
2. Kelkar G, Subhadra K, Chengappa RK. Nutrition
knowledge, attitude and practices of competitive
Indian sportsmen. Ind J Nutr Dietet 2005; 43:
293 – 303.
3. Raina U et al. Basic food preparation-a complete
manual. Third Edition. Orient Longman 2002.
4. Gopalan C, Ramasastri BV and Balasubramanian
SC. Nutritive value of Indian foods. Indian
Council of Medical Research. Reprint 2004.
5. Satyanarayana K, Venkataramana Y, Someswara
Rao M, Anuradha A and Narasinga Rao BS.
Quantitative assessment of physical activity and
energy expenditure pattern among rural working
women. In: Update Growth, pp 197-205 [K.N.
Agarwal and B.D. Bhatia, editors]. Varanasi,
India: Banaras Hindu University. 1988.
6. NIN / ICMR Recommended dietary intakes for
Indian sports men and women, 1985.
7. Indian Council of Medical Research. Nutrient
Requirements and Recommended Dietary
Allowances for Indians, 1990.
8. Rao BSN. Nutrient requirements of sportsperson
and athletes. Proc Nutr Soc India, 1996; 43: 79-
103.
9. Cann C, Martin M, Genant H, Jaffe R. Decreased
spinal mineral content in amenorrheic women.
JAMA 1984; 251:626.
10. Nelson M, Fisher E, Catsos P, Meredith C, Turksoy
R, Evans W. Diet and bone status in amenorrheic
runners. Am. J Clin Nutr, 1986; 43: 910.
Jain R et al: Dietary Profile of Sports Women
156
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Integrated Child Development Services (ICDS)
scheme, recognized as the world’s most unique largest
community based outreach system for women and
child development, had been launched in 1975 in only
33 blocks on experimental basis. With immense success
in the initial years it was periodically expanded to the
extent that in the Tenth Five Year Plan ICDS scheme
was universalized in the whole country1.
But merely increasing the infrastructure/
availability of the services does not increase the
utilization of the services from the centre. It depends
on many factors and one of them is client’s satisfaction.
For client’s satisfaction critical factor is the quality of
services. Client rated quality as ‘very good’ when they
found three elements viz Doctors, Facilities and Workers
to be of good quality2. The good quality of the services
is necessary for acceptability of a programme in a
community as it determines how beneficiaries would
perceive about the services and make further demand.
Though AWCs have long standing reputation among
community by its existence but how far it is successful
to satisfy the expectations of the end users through its
services is not clear. Therefore, the present study was
undertaken to assess perception of the beneficiaries
for the quality of the services provided from AWCs.
Short Communication
Perception Regarding Quality of Services
in Urban ICDS Blocks in Delhi
*A. Davey1, S. Davey2, U. Datta3
1Senior Resident in Subharti Medical College, Meerut; 2Medical Officer, Government of Uttar Pradesh. 3Reader,
Education and Training Department, NIHFW, New Delhi *Corresponding author: anu_davey@yahoo.co.in
Summary
The good quality of the services is an important determinant for acceptance of a programme in a
community. It not only enhances the credibility of a worker at the ground level but also generate
the demand for the services. In this paper perception for the quality of the services was assessed
through the exit interview of the beneficiaries at the Anganwadi centres (AWCs). 200 beneficiaries
were included from 20 AWCs in a period of one and half month. 52.5% respondents were
dissatisfied for the services provided from the AWC for one or more reason. The most common
reason mentioned was the not easy accessibility of the AWC and less space available at the AWC
(68.6%), followed by the poor quality of the food distributed (66.7%) and irregular pre school
education (57.1%) from AWCs.
The cross-sectional community based study was
conducted during July-August 2004, among 200
women respondents selected through stratified random
sampling technique. In Delhi total 28 ICDS blocks are
existing, 5 in rural areas and remaining in urban slums
of nine districts. The study blocks running in the urban
areas are divided into four geographical zones by
arbitrary lines. From each zone one ICDS block was
selected randomly and five anganwadi centers were
selected from each block by systemic random selection
technique, thus a total of 20 AWCs were included. At
each AWC, every third respondents was interviewed
in depth at the exit by open-ended interview schedule,
till they make sub sample size of 10. Thus, total sample
size of the respondents was 200. Respondents were
comprised of pregnant women, lactating mothers and
mothers of the children registered with the anganwadi
centers.
Respondent women were interviewed to ascertain
their opinion on various aspects like approachability
of AWC, utilization of services by the beneficiaries and
their satisfaction towards services of the AWCs.
Out of 200 respondents interviewed, 72.5% (145)
were mothers of the children, 16.5% (33) pregnant
women and 11% (22) lactating women. Out of 145
157
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
children (for whom mothers are taken as respondents),
28.3% (41) were in the age group of less than 3 years
and 71.7% (104) in the age group of 3-6 years. Overall,
44% respondents (88) were illiterate and 56% (112)
were literate. Majority of the respondents (70%) were
staying in the area since more than 5 years.
When beneficiaries were asked about how they
came to know about the AWC running in their areas,
37.5% said by themselves, 23% said from their mother
in law, 20% from neighbors, 12% by helpers and 2.5%
by ANM. Only 5% women came to know about the
AWCs through AWWs, indicating their poor
approachability in the community.
89% of the respondents had mentioned that
AWW had visited them in last one year. 51.7%
respondents said that their frequency for visit was once
in 3 months. Reasons for visit were reported to be polio
vaccination (69%), immunization services (51.7%);
health education (11.8%); nutrition services (11.2%)
and pre-school education was the least common reason
(1.1%) mentioned by the respondents.
Overall drive against Polio might have influenced
the worker to go house to house. Pre school education
could be the neglected component of the services
delivered from AWC, so did the respondents mention
it as the least common reason.
Regarding utilization of services for the children
all the mothers mentioned that they received
supplementary nutrition from the AWCs. 56.6%
mothers told growth monitoring was done of their
children in last 6 months. Only 15.9 % had utilized
services for immunization purposes from the AWCs.
However, Benjamin et al3 reported growth monitoring
was rare phenomena in Ludhiana district and Sharma
A et al in the national evaluation of the ICDS services
had observed that 36.3% of the AWWs were not able
to monitor growth of the children4.
For the 104 children of the preschool age group,
only 42.3% mothers mentioned about utilization of
services for preschool education from the AWCs, but
not regularly. Irregular services of pre school education
could be due to secondary emphasis for the monitoring
of the AWW performance as primary importance is
given to their growth monitoring activities and
supplementary nutrition distribution and may be due
to non availability of space and lack of education and
teaching aids at the AWC. Roy S et al had also
concluded in their interventional study that lack of
conceptual curiosity and skills of the AWWs also limit
play way activities at the AWCs 5.
94.5 % of the pregnant and lactating women were
mainly utilizing the services for the supplementary
nutrition. Only 23.6% women told they were given
health and nutrition education and 5.5% utilized AWCs
for immunization services. None of pregnant and
lactating women had ever received tablet iron and folic
acid from the AWCs in last one year and had never
been provided antenatal or postnatal care. Benjamin
et al had also observed less dispensing of Iron and
Folic Acid to the pregnant and lactating women by the
AWWs in the Ludhiana district 3.
47.5% (95) of the respondents were satisfied with
the services provided from the AWCs. Rest of the 105
dissatisfied beneficiaries (52.5%) had mentioned
various reasons (Table 1); the most common reason
being non-accessibility of the AWCs and inadequate
space to run AWCs (68.6%). Other studies6, 7 also
reported distance/unapproachable state as reasons for
non-utilization of services.
Further analysis revealed that, 22 of 70 (31.4%)
dissatisfied respondents due to poor quality of food
and 20 of 72 (27.8%) dissatisfied respondents due non
accessibility, were satisfied with the overall functioning
of the AWCs; however all the mothers, who were not
satisfied with the pre school services, were also not
Table 1: Distribution of the respondents
by their satisfaction for services provided
from AWC (n=200)
Variables Numbers (%)
Satisfied with the services
Yes 95 (47.5)
No 105 (52.5)
Reasons for non satisfaction
Non-accessibility 72 (68.6)
Less space at AWC 72 (68.6)
Poor quality of food 70 (66.7)
Irregular pre school education 60 (57.1)
No frequent change in recipe 45 (42.9)
No immunization at center 45 (42.9)
Davey A et al: Quality of Services in ICDS in Delhi
158
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
satisfied with the services of AWCs.
The findings of the present study also indicated
that client’s satisfaction about quality influenced the
acceptance and utilization of services. Therefore,
function of the AWWs should not be restricted to the
distributing of supplementary nutrition to beneficiaries
only, but need to focus to raise satisfaction level of the
end users by developing good rapport through periodic
survey and delivering optimum level of services.
References:
1. Govt. of India. Nutrition and Food, Tenth Five
Year Plan, 2002; p 341-346.
2. State of India’s Health. Voluntary Health
Association of India, 1992; pp 53-57.
3. Benzamin AI, Panda P and Zachariah P. Maternal
and Child Health Services in Dehlon block of
Ludhiana district: Results of the ICDS evaluation
survey. Health and Population: Perspective and
Issues, 1994; 17(1-2): 67-85.
4. Sharma A. National consultation to review the
existing guidelines in ICDS scheme in the field of
Health and Nutrition. Indian Pediatrics 2001;
38:721-731.
5. Roy S, Parmar P; Sundram. Impact of the
intervention programme on the knowledge,
content and skills of AWW and selected
conceptual skills for the pre school, Indian Journal
of Maternal and Child Health 1994 Jan-March; 5
(1): 20-22.
6. Agnihotri S P, Pandy D N, Nandan D. The impact
of Rural Health Services in Agra. Indian Journal
of Public Health 1984; 28 (1): 25-29.
7. Jain M, Nandan D, Misra S.K. Qualitative
assessment of health seeking behaviour and
perception regarding quality of health care
services among rural community of district Agra.
Indian Journal of Community Medicine 2006; 31
(3): 140-143.
Davey A et al: Quality of Services in ICDS in Delhi
Attention
All the newly enrolled Life Members
of Indian Public Health Association
Dear Sir / Madam
You are aware that the 53rd All India Annual Conference of IPHA is going to be held from 9th to
11th January 2009 at Kempegowda Institute of Medical Sciences (KIMS), Bangalore – 560070, Karnataka.
During the conference Life Membership Certificate (MIPHA Scroll) will be distributed. In case, you are
unable to attend the conference at Bangalore, the Certificate will be sent to you. The certificate can also
be collected from the HQ Secretariat at Kolkata personally or through your authorized representative.
Sd/-
Dr. Madhumita Dobe
Secretary General, IPHA
159
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
A good number of neonatal morbidity and
mortality is attributed to improper delivery and
newborn care practices1. Neonatal care practices
depend on the knowledge, attitude and practice of the
community as well as the availability and accessibility
of the services. Several interventions have been
adopted to address the unmet needs for Basic
Reproductive and Child Health Services, supplies and
infrastructures since 19722. In spite of all this, neonatal
morbidity and mortality are considerably high in our
country and neonatal mortality accounts for two-third
of the infant deaths. 40 – 70% of neonatal deaths are
seen during 1st week of life and majority occurs at
home. Presently in our country only 34% births occur
in health institution3 and 42% deliveries are assisted
by skilled attendants4. There are considerable local
variations in delivery and newborn care practices
adopted by the community and interventions must take
into account the prevailing practices in the area. It is
highly relevant to generate area specific data regarding
some of the key delivery and newborn care practices
at the community level to initiate appropriate
intervention.
The present study was conducted in a rural block
of West Bengal to assess the proportion of home
deliveries, to identify the different categories of care
providers and to find out the prevailing practices
regarding some essential components of newborn care.
Short Communication
A Study on Delivery and Newborn Care Practices in a
Rural Block of West Bengal
*P. Das1, S. Ghosh2, M. Ghosh3, A. Mandal4
Summary
A cross-sectional study was conducted in a rural block of the State of West Bengal to generate
area specific data on the proportion of home deliveries and certain newborn care practices
prevalent in that area. The study was done through house-to-house survey among 165 mothers
who delivered in last six months. 83.6% deliveries were conducted at home and untrained persons
attended 36.3% deliveries. Bath within 24 hours of delivery was given to 17.58% newborns. Birth-
weight was not recorded in 38.18%. High proportion of newborns, 78.5%, was given prelacteal
feeding. The health system should urgently address the deficiencies in the delivery and newborn
care practices in the study area.
The study was conducted in Basirhat – 1 block of
North-24 Parganas district of West Bengal. The block
had 19 subcenters and have a population of 1, 59,000.
The respondents were mothers, who delivered live
babies in the last six months (January to June 2005).
Sample size was estimated to be 144 to provide
coverage estimate at 95% confidence level and 8%
error margin at 40% previous coverage level. Single-
stage random sampling was used for selection of the
mothers. All 19 subcentres were taken and from each
sub-centre 10 mothers were selected randomly. 25
mothers denied providing information. Finally 165
mothers were studied.
Majority of the deliveries, 138 (83.6%), were
conducted at home. Only 26 (15.8%) deliveries took
place at government health facilities (Table 1). Similar
high proportion of home deliveries were observed in
other studies like one in Jamnagar, Gujrat5.
More than one-third of the deliveries (36.3%)
were conducted by untrained persons. Untrained dais
attended 31.5% deliveries and 4.8% deliveries were
by friends, relatives and unqualified practitioners.
Skilled birth attendance was available in only 14%
deliveries (nurse 10.4% and doctors 3.6%) (Table 1).
17.6% newborns were given bath within 24 hours
of delivery. Bath-after-delivery was found higher
(32.0%) in a study in Egypt6. Birth-weight was not
1Assistant Professor, 3Ex-Professor, Community Medicine, 2Assistant Professor, Psychiatry, 4Principal, N R S Medical
College, Kolkata, West Bengal. *Corresponding author: palash_kal@yahoo.co.in
160
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
recorded in 63 (38.2%) newborns. This was similar
(33.33%) to study done in Jamnagar district of Gujrat5
but very high in comparison to the study result (4.0%)
obtained from a hilly district of North India7. Among
102 (61.8%) newborns where birth weights were
recorded, 19 (18.6%) were low birth weight (Table 2).
Newborn feeding practices were studied and it
was found that breast-feeding was almost universally
practiced (98.79%) among the study population.
Breast-feeding was initiated within half-an-hour in
42.4% infants. In 25.5%, it was initiated between half-
an-hour to one hour and in 32.1% beyond one hour.
The practice of prelacteal feeding was found to be
highly prevalent (78.2%). Varieties of prelacteal feed
observed, such as plain water (17.6%), sugar water
(9.8%) and honey (51.1%). Honey was found
predominant prelacteal food in another study done at
hilly district of North India6 (46.14%) but sugar water
was found to be dominant prelacteal food in Egypt
study6.
The present study identified several deficiencies
in delivery and newborn care practices in the study
area. The health system must urgently address the
issues by adopting appropriate behaviour change
communication strategies.
References:
1. Reproductive and Child Health Module for Health
Workers Female (ANM). National Institute of
Health and Family Welfare, New Delhi, 2000.
2. National Population Policy, 2000. Ministry of
Health and Family Welfare, Govt. of India,
Nirman Bhavan, New Delhi.
3. National Family Health Survey (NFHS-2), Key
findings, 1998-99. International Institute of
Population Science, Deonar, Bombay, 2001, 13-
4.
4. The state of the World Children 2004. UNICEF,
New York, USA.
5. Suda Yadav, BS Yadav, SS Nagar, A Study on
Neonatal Mortality in Jamnagar District of Gujrat,
Indian Journal of Community Medicine 1998; 23
(3):130-135.
6. Home Neonatal Care Practices in Rural Egypt
during 1st Week of Life Md. H. Hussein et al http:/
/www.gfmer.ch/ IAMANEH_ISMANEH_Cairo_
2006
7. Anmol K Gupta, Rajesh K Sood, Ajay Vatsayan,
Dineswas K Dhadwal, Surender K Ahluwalia,
Rajesh K Sharma; Breast Feeding Practices in
Rural and Urban Communities in a Hilly District
of North India, Indian Journal of Community
Medicine 1997; 22 (1) : 33-37.
Table 1: Place of delivery and assistance
during delivery (n=165)
Factors Number (%)
Place of delivery
Home 138 (83.6)
Health Centre 4 (2.4)
Hospital 22 (13.4)
Nursing Home 1 (0.6)
Provider Type:
Doctor 6 (3.6)
Nurse 17 (10.4)
Trained Dai 62 (49.7)
Untrained Dai 52 (31.5)
Others 8 (4.8)
Table 2: Newborn care practices: Bath-
after-delivery and birth weight (n=165)
Practices Number (%)
Bath-after-Delivery
Bath given 29 (17.6)
Bath not given 32 (80.0)
Do not know 14 (2.4)
Birth Weight
LBW 19 (18.6)
Normal 83 (81.4)
Total 102 (61.8)
Birth Weight not taken 63 (38.2)
Initiation of breast feeding
Within ½ hour 70 (42.4)
½ - 1 hour 42 (25.5)
After 1 hour 53 (32.1)
Prelacteal feeding
Honey 84 (51.1)
Sugar water 16 (9.8)
Plain water 29 (17.6)
Total 129 (78.2)
Das P et al: Delivery Practices in Rural Block of West Bengal
161
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Hospital discharge records are important source
of data which can provide important information and
serve as an essential tool for decision making.
Furthermore it is an indicator of early warning signal
for impending health problems1.
In District Civil Hospital (DCH), Belgaum,
diagnoses are coded as per International Classification
of Diseases, 10th Revision (ICD-10). As per World
Health Organization (WHO) there are 21 classifications
under certain infectious and parasitic diseases2.
Infectious diseases caused by pathogenic bacteria,
viruses and protozoa are the most common and wide
spread health risk associated with drinking water3. In
New Zealand, rates of some infectious diseases
continue to remain high for a developed country and
there are also large inequities in the distribution of this
burden4. Globally waterborne and sanitation-related
infections are one of the major contributors to diseases
burden and mortality5. Infectious diseases kill more
than 11 million people a year and diminish the lives of
countless others6. Virtually all deaths due to infectious
diseases occur in low-and middle-income countries.
This study attempts to find out the distribution of
hospitalisation due to infectious and parasitic diseases.
Short communication
Hospitalisation due to Infectious and Parasitic Diseases in
District Civil Hospital, Belgaum, Karnataka
*A. C. Naik1, S. Bhat1, S. D. Kholkute1
Summary
To assess the burden of infectious and parasitic diseases on hospital services at District Civil
Hospital (DCH) Belgaum, a retrospective study was carried out using discharge records
concerning 8506 inpatients due to infectious and parasitic diseases among 95655 patients admitted
for all causes during the reference period 2000-2003. Out of the 21 causes of infectious and parasitic
diseases, only 5 contributed maximally towards hospital admission. The most frequent cause
was intestinal infections (44.0%) followed by tuberculosis (35.4%). 57.5% of these admissions
were from the productive age group of 20-54 years. Tuberculosis is the most important disease in
terms of hospital bed days (59.7%). Tuberculosis and intestinal infectious diseases represent more
than three-fourth of the overall burden in terms of hospital bed days.
This is a retrospective study carried out at DCH,
Belgaum based on ICD-10 diagnosed codes devised
by WHO. DCH is a major government multi-specialty
hospital in Belgaum district having 740 beds and is
attached to a medical college. The hospital also has a
outpatient department (approximately 377000
consultations annually) and a community health
department.
Out of 95655 patients admitted during the four
years reference period (2000-2003), 8506 patients
admitted were due to infectious and parasitic diseases.
Data was collected during 2005-06 and analysis made
using Statistical Package for Social Sciences (SPSS)
version 13.0 software. If any patient was readmitted
after discharge this was considered as a new patient.
The multiple co-infected patients are included in the
frequency distribution based on the primary infection
and not counted in other co-infection categories. From
discharge certificates two things were noted e.g.
frequency of admissions due to the condition, and
duration of the service provided (expressed in days of
hospital stay).
Out of 95655 admissions, 8506 patients were
admitted due to infectious and parasitic diseases. The
admissions by age showed that proportion of
1Regional Medical Research Centre, Indian Council of Medical Research, Nehru Nagar, Belgaum, Karnataka.
*Corresponding author: ashokcnaik@yahoo.com
162
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
admissions below 5 years of the children constituted
12.7%. Most productive age group (20-54 years)
constituted the maximum (57.5%) number of patients.
Although male admissions are more in all the 5
infectious diseases, in case of tuberculosis and intestinal
infections, a statistically significant difference between
male and female admissions was observed (p<0.001).
Among the 21 classification of infectious and
parasitic diseases, only five contributed towards 93%
of burden on hospital services namely intestinal
infections, tuberculosis, other bacterial diseases
(Septicemia, Leprosy, Tetanus, etc), HIV and protozoal
diseases. Intestinal infectious diseases contributed
maximum of 44% with proportional mortality rate
(PMR) of 6.9%. Diarrhea, gastroenteritis and fever
(96%) were more commonly reported among the 9
categories of intestinal infectious diseases in the DCH.
Tuberculosis with 35.4% of admissions with a PMR of
44.6% was the second highest. Even though
contribution from other bacterial diseases was only
5.9%, but PMR was considerably high (34%).
Percentage of admissions due to HIV was only 4.5%;
however PMR was 7.6%. Protozoal diseases
contributed least (3.3%) compared to the above four
categories of infectious diseases with PMR of 1.4%
(Table-1). Malaria (85.7%) was more commonly
reported among 11 categories of protozoal diseases
and in 3.1% cases HIV-TB co-infection was found.
Considering the number of bed days occupied
disease wise, tuberculosis was the major contributor
with 59.7% and average length of stay (ALOS) per
patient was 18 days. The next category was the
intestinal infections with 21.2% of bed days occupied
with ALOS of 5 days. Other bacterial diseases
(Septicemia, Leprosy, Tetanus, etc) also contributed a
significant number of bed days with 7.6% and high
ALOS of 13 days. HIV patients occupied 4.1% of bed
days with ALOS of 10 days.
The total number of children below 5 years
admitted was 1084. The highest number of admissions
was due to intestinal infectious diseases (72%) with
PMR 10.1%. The admission for tuberculosis was 10.4%
with PMR of 11.2%. In case of children, other bacterial
conditions also contributed 10.1% and PMR was very
high with 70.9% compared to other infectious diseases.
Although hospital data has some limitations, but
it provide important information for planning,
evaluation of hospital services and epidemiological
studies.
Using the percentage of hospital bed days (related
to both frequency of admission and duration of stay)
as a proxy of a condition’s relative burden on hospital
services, childhood diseases as a whole account for
less than 15% of the total burden. In a similar study
conducted in Uganda, it was observed to be more than
one-fourth of the total burden1. However the study
referred above was carried out after a war and famine
while the present study was conducted in normal
situation.
The present study reveals that the total load in all
age groups of intestinal infectious diseases was 44%
where as in case of children below 5 years this was
higher (72% of 1084 admissions). These diseases are
Table 1: Different parameters for the five leading causes of admissions in District Civil
Hospital, Belgaum.
Causes Admissions Bed days ALOS(days) Deaths PMR (%)
No (%) No (%) No (%)
Intestinal Infectious Diseases (A00–A09) 3740 (44.0) 18904 (21.2) 5 48 (1.3) 6.9
Tuberculosis (A15–A19) 3013 (35.4) 53354 (59.7) 18 312 (10.4) 44.6
Other Bacterial Diseases (A30–A49) 501 (5.9) 6572 (7.6) 13 238 (47.5) 34.0
HIV diseases (B20–B24) 380 (4.5) 3623 (4.1) 10 53 (13.9) 7.6
Protozoal Diseases (B50–B64) 280 (3.3) 2176 (2.4) 8 10 (3.6) 1.4
Other Infectious Diseases* 592 (7.0) 4746 (5.3) 8 38 (6.4) 5.4
Total 8506 (100.0) 89375 (100.0) 11 699 (8.2) 100.0
*Other Infectious Diseases=A20–A28, A50–B19, B25–B49, B65–B99. PMR=Proportional mortality rate;
ALOS=Average length of stay.
Naik AC et al: Burden of Infections & Parasitic Diseases in a District Hospital of Karnataka
163
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
caused by contamination of human/animal feces and
pathogenic microorganisms in drinking
water. Infectious diseases caused by pathogenic
bacteria, viruses, and protozoa are the most common.
There is an urgent need to control this disease to reduce
the hospital burden. The ALOS for TB patients was
18 days in DCH, Belgaum compared to 57 days in
Lacor Hospital, Uganda and 86 days in Russia1, 7.
However study undertaken in USA has found ALOS
for TB patients is 14 days8 which is comparable to our
results. The huge difference between Uganda and
Russian studies compared to Indian and USA studies
could be treatment policy for TB patients. TB patients
require labor intensive care and a high volume of
laboratory, radiology and ancillary services. In other
words, the burden of TB in terms of use of hospital
services is much higher than its burden in terms of
number of admissions. It is expected that the burden
of TB shall be reduced in future as DOTS strategy is
being implemented in Belgaum district since 2002.
The percentage of admissions due to HIV was
only 4.5% of the total admissions. Further, HIV patients
ALOS was 10 days compared to tuberculosis (18 days)
and other bacterial diseases (13 days). The interesting
observation in the present study is HIV-TB co-infected
patients admission was 3.1% of the infectious and
parasitic diseases which is comparable to the hospital
data from USA (3.2%)8.
Thus, the present study clearly suggests that
intestinal infectious diseases and tuberculosis cause
maximum burden on hospital services at DCH,
Belgaum which can be reduced by proper and timely
interventions. Burden of intestinal infections can be
reduced by providing potable water and proper
sanitary measures. The integration of preventive and
curative care, implementing health education
programs, improving the accessibility of health facilities
and the availability of effective treatment, are also
crucial for controlling infectious diseases. Burden of
TB on hospital services can also be considerably
reduced by proper awareness about DOTS (Directly
Observed Treatment Short-course).
Acknowledgments
We wish to thank District Surgeon and Mr. Keshav
Rao of district civil hospital, Belgaum for permitting to
utilize the data. We thank Mr. Vinayak Upadhya and
Mr. Shankar V. Belchad for support in data entry.
References:
1. Accorsi S, Fabiani M, Lukwiya M, Onek PA, Mattei
PD, Declich S. The Increasing Burden of Infectious
Diseases on Hospital Services at St. Mary’s
Hospital Lacor, Gulu, Uganda. Am. J. Trop. Hyg.
2001; 64(3, 4): 154-158.
2. World Health Organization. International
Statistical Classification of Diseases and Related
Health Problems, tenth revision (ICD-10).
Geneva: World Health Organization, 1994.
3. World Health Organization. Report on Infectious
Diseases. World Health Organization, 1999. http:/
/www.who.int/infectious-disease-report (Accessed
on 06/03/2007).
4. Clair FM, Martin T, Michael B. A re-appraisal of
the burden of infectious disease in New Zealand:
aggregate estimates of morbidity and mortality.
NZMA 2002; 115:1-8.
5. Hunter PR. Climate change and waterborne and
vector-borne diseases. Journal of Applied
Microbiology 2003; 94:37S-46S.
6. Disease Control Priorities Project. Infectious
diseases. Changes in Individual Behavior Could
Limit the Spread of Infectious Diseases. Disease
Control Priorities Project, 2006. http://
www.dcp2.org (Accessed on 08/03/2007).
7. Marx FM, Atun RA, Jakubowiak, Mckee M, Coker
RJ. Reform of tuberculosis control and DOTS
within Russian public health system: an ecological
study. European Journal of Public Health 2006;
17 (no.1):98-103.
8. Hansel NN, Merriman B, Haponic EF, Diette GB.
Hospitalization for Tuberculosis in the United
States in 2000: Predictors of In-Hospital Mortality.
Chest 2004; 126: 1079-1086.
Naik AC et al: Burden of Infections & Parasitic Diseases in a District Hospital of Karnataka
164
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Introduction
Homelessness has major public health
implications for not only those affected but also for
the general population. Homeless people are potential
reservoirs of infectious diseases like tuberculosis, AIDS
etc. Homelessness among youth leads to increased
crime and substance use related disorders and is of
public concern. Health in homelessness state is
compromised by physical environment including
hazards of street life, poor nutrition, lack of facilities to
maintain personal hygiene1 and increased risk of
infectious diseases through crowding, negligence
towards disease and enforced lifestyle2. Initial health
impairments and disabilities can lead to homelessness
and a vicious cycle of deprivation.
However, homelessness is not recognized as a
public health problem. An inadequate information base
has affected the public health response to
homelessness. Health care providers need to
acknowledge that there are an unknown, but large,
number of persons who become homeless as a result
of a residual impairment and disability and also as
being victim of social and economic inequity.
Review Article
Homelessness: A Hidden Public Health Problem
*S. Patra1, K. Anand1
Summary:
Homelessness is a problem, which affects not only the people who are homeless but the whole
society. This problem is not well recognized among the public health professionals. This paper
attempts to discuss the issues in the context of homelessness starting from the definition used to
methodology of estimation of their numbers as well as their health problems and health care
needs. There is lack of data on the health problems of homelessness from India. There is no
special health or social programmes or services for this subsection of the society. The existing
number of shelters is inadequate and as there are multiple barriers, which prevent them to have
proper access to the existing health care system. With the changing social and economic scenario,
homelessness is likely to increase. We need to recognize homelessness as a public health problem
and attempt to target this group for special care in order to promote equity in health system.
Key words: Homeless, shelter, census, barriers
This paper tries to review issues related to
homelessness in general and specifically in the Indian
context. We did a review of literature by searching
through electronic database like Pubmed and Indmed
and google. Key words used for search were “homeless
people, health problems, causes, and health systems”
in different combinations. We also did manual search
for articles published in un-indexed journals, and
reviewed different research articles both published as
well as unpublished.
Definition of Homelessness
There is wide variation in the definition of
homelessness, between studies, between countries, and
often definition has been affected by services and social
support provided to them. A wider definition of
homelessness is the absence of a personal, permanent,
adequate dwelling.
Homeless Assistance Act of 19873 of USA defined
‘homeless’ to mean: An individual who lacks a fixed,
regular, and adequate night-time residence; or who
has a primary night-time residence that is a supervised
1Centre for community Medicine, All India Institute of Medical Sciences, New Delhi.
*Corresponding Author: somadattap@gmail.com
165
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
publicly or privately operated shelter designed to
provide temporary living accommodations or a public
or private place not designed for, or ordinarily used
as, regular sleeping accommodations for human
beings.
The Census of India (2001) uses the notion of
‘houseless population’, defined as persons who are not
living in ‘census houses’ but are in houseless
households. Houseless household, as the name
suggests is an oxymoron, has been defined as those
who do not live in buildings or census houses but live
in the open on roadside, pavements, in hume pipes,
under flyovers and staircases, or in open in places of
worship, railway platforms etc. are to be treated as
houseless household 4.
A uniform definition of homelessness is essential
in order to have recognition of the condition and policy
towards homelessness.
Counting the Homeless
By very nature of their mode of living it is very
difficult to enumerate the homeless. Some strategies
for enumerating are: one-night counts or point in time;
extrapolations from partial counts; windshield street
surveys; adaptations of area probability designs;
service-based designs5. In India the method adopted
was point in time estimation. Enumeration of the
houseless households was done on the night of 28th
February, 2001 when the enumerators on basis of pre
identified areas visited places of worships, railway
platforms, and flyovers etc where such households were
generally found. There are 447,552 houseless
households consisting of 1,943,476 persons in the
country4.
Point-in-time counts method attempts to count
all the people who are homeless on a given day or
during a given week. There are many people who
experience homelessness at a particular point of time
but do not remain homeless. Another important
methodological issue is regardless of the time period
over which the study was conducted, many people will
not be counted because they are not in places
researchers can easily find. Due to both these reasons,
magnitude of the problem of the homelessness is likely
to be unreliable by point in time method.
Capture-recapture methods overcome problems
of ascertainment by calculating the size of the
unobserved population and completeness of survey.
The plant-capture method was used to estimate the
number of homeless people in southern Manhattan as
part of the 1990 US decennial census6 and to estimate
number of street children in Brazil7. Underestimation
was to the tune of 63% in Brazil.
Identifying people who are at risk of
homelessness
There are a certain subgroups of persons who
are of high risk for becoming homeless. These include
persons who live in poverty, have mental disability,
victimized persons (domestic violence), persons with
drug and alcohol addiction or health problems, and
persons who lack sufficient social support 8. Other
persons at risk are single women with young children
and unskilled workers9 and people who are victims of
natural disaster, racial discrimination, or those released
from prison.
In pediatric homeless population, we find 90%
of street children are working children who live with
their families. Remaining 10% are abandoned and
neglected children with no family ties10. Insufficient
research has been done to look for the factors
compelling children to make street, their home. In a
study, in India, it was found that the most common
reason for running away from home was; beating by
parents or relatives, followed by a desire for economic
independence, both parents dead, argument with
parent etc11.
Health problems of homeless people
Studies on health of homeless have found that
there are high prevalence of premature death and
diseases like respiratory tract disease, sexually
transmitted diseases and chronic diseases12-21 (Table
1). In Baltimore study2 average number of problems
per person in men were 8.3 and in women it was 9.2.
Chronic diseases often go unrecognized and
untreated21. Even if the condition is detected and
treated, lack of compliance and consistent follow-up
often results in disease progression, disability, morbidity,
and premature death22. Besides physical health
problems, mental health problems, substance use
disorders and behavioral problems23-31 are also very
high among this subsection of the society
(Table 2). This section clearly highlights that there is
Patra S et al: Homelessness: A Hidden Public Health Problem
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
little data from India on health problems of homeless.
The data are mainly from the western world especially
US for many of the health conditions.
Barriers to health care seeking
Homeless people are also plagued by multiple
internal and external barriers to obtain effective
primary care32. Internal barriers include denial of
health problems and pressure to fulfill needs like
obtaining food, clothing and shelter as well as lack of
self-esteem and feelings of worthlessness. External
barriers include unavailable or fragmented health care
services, and prejudices and frustrations on part of
health care professionals8. One-fifth of homeless adults
who had not obtained needed medical care stated that
this was due to inability to pay for medical services33.
Table 1: Summary of selected studies on health problems of homeless
Domain Authors/ Year Place of Study Major Findings
Reference
Premature-death
MMWR12 1987 Atlanta Median age at death: black men 43, white men 53 years
MMWR13 1991 San Francisco Average age at death was 41 years
Hibbs et al14 1994 Philadelphia Age-adjusted mortality rate 4 times that of general
population
Hwang et al15 1997 Boston Average age at death : 47 years
Hwang et al16 2000 Toronto Mortality rate ratios were 8.3 for men aged 18 to 24 years,
3.7 for aged 25 to 44 years, and 2.3 for aged 45 to 64
years higher compared to general population
Sexual Health
Hwang et al15 1997 Boston AIDS was the leading cause of death among persons 25
to 44 years of age
Ray Sk etal17 2001 Kolkata, India Health problems of women were leucorrhoea, menstrual
irregularities, infertility and STDs and 3/4th of this illness
was uncared for.
Talukdar A et al18 2007 Kolkata, India 90% of married homeless men visited Commercial Sex
Workers, but 3.3% consistently used condoms.
Brito VO et al19 2007 Sao Paulo, Brazil Prevalences were 1.8% for HIV, 30.6% for previous hepatitis
B infection, 3.3% for acute infection by hepatitis B virus, and
5.7% for syphilis. Consistent use of condoms was referred to
by 21.3% and injecting drugs by 3% of them.
Respiratory Problems
Hwang et al15 1997 Boston Pneumonia and influenza, were found to cause death in
homeless persons
WHO20 1999 London, 25 and 30 percent of population were reported to be
San Franscico infected with TB, chronic diseases
Ropers R etal21 1987 US 40% reported at least one chronic health problem
Hwang et al16 1997 Boston Heart disease and cancer were the leading causes of death
among persons 45 to 64 years of age
Patra S et al: Homelessness: A Hidden Public Health Problem
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Homeless people frequently lack identification or other
documentation to prove indigent status in order to
qualify for free or reduced services in mainstream
health care settings. For this reason even if needed
they are denied treatment under national programmes
like RNTCP (Revised National Tuberculosis Control
Programme). Similar reasons were also found by Heath
Need Assessment Survey team of Aashray Adhikar
Abhyan34. Often the homeless people are denied
services because of their appearance35. Homeless
adolescents confront further hurdles stemming from
their age and developmental stage. These include lack
of knowledge of clinic sites, fear of not being taken
seriously and fears of police or social services
involvement36.
Available health care facilities:
In India we have only shelters for homeless
people. In Delhi, the capital of India, there is a total of
22 temporary and 12 permanent shelters with a
capacity of 400034. By any estimate over 1 lakh people
Table-2: Summary of selected studies on psychosocial and behavioral aspects of homeless
Domain Authors/ Year Place of Study Major Findings
Reference
Substance use disorder and high-risk behavior
Shaffer D et al23 1984 New York 70% of the runaways were using illegal drugs
MMWR13 1991 San Francisco Drugs or alcohol were detected in 78% of the study
population.
UNDP24 2002 14 states of India Out of all substance dependents about 1/4th was homeless.
Ahmedabad (83%), Hyderabad (65%), Mumbai (54%) and
Delhi (39%) reported a higher prevalence
Kramer CB et al25 2008 Seattle More abuse of alcohol (80.6% vs 12.8% and drug (59.4% vs
12.8%) compared to domicile population.
Violence
Hwang et al15 1997 Boston Homicide, injuries, and poisoning were the leading causes of
death among persons 18 to 24 years of age.
Kramer CB et al25 2008 Seattle Homeless people have more severe injuries(13.9% vs 2.0%,
P < .001), assault by burning (17.8% vs 11.2%, p < .001)
Physical Abuse and Victimization
Banerjee SR26 2001 Calcutta, India 26.9% of study children reported to experience physical
abuse.
Rosenthal D et al27 2003 Australia Incidence of involuntary sex among homeless young people
is considerably higher than in the general population
Kushel MB et al28 2003 San Franssico Housing is associated with lower rates of sexual assault
among women
Rew L et al29 2003 Texas Sixty percent of the sample reported sexual abuse.
Mental Health Problems
Tyler et al (30) 2004 Seattle Dissociative behavior is widespread among these youth and
may pose a serious mental health concern
William R Breakey (2)1989 Baltimore Major mental illnesses were present among 42% of men and
48.7% of women
Whitbeck LB et al (31)2007 USA 35.5% of the adolescent met lifetime criteria for Post
Traumatic Stress Disorder. Significant correlates were age
of adolescent, being female, having experienced serious
physical abuse and/or sexual abuse etc.
Patra S et al: Homelessness: A Hidden Public Health Problem
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
are homeless in Delhi. In June 2000, Ashray Adhikar
Abhiyan (a NGO) counted 52,765 homeless people,
in certain areas of Delhi alone. Even Delhi
Development Authority (DDA) admits that at least 1%
of the population is homeless, i.e. 1.4 lakh at
present”37.
More or less the shelters just provide physical
protection and are not linked to any health intervention
programs of the government. In one survey undertaken
by Aashray Adhikar Abhyan, Institute of Human
Behaviour and Allied Sciences34 it was found that
homeless population considered visit or these places
unfruitful for want of proper identity document and
lack of support to guide them through cumbersome
procedure, many feared past hostile experiences of
discrimination and neglect.
The issue of homelessness and health system has
not been addressed at all in India. Thus, at this stage
we have to learn from the experience of other countries.
The Health Care for the Homeless (HCH),
program USA38 emphasizes a multi-disciplinary
approach to deliver services, combining aggressive
street outreach with primary care, mental health and
substance abuse services.
In Philadelphia and New York City a pilot project
has started with aim to identify neighbourhoods from
where a disproportionate number of homeless come
and focus on activities like job training, health care
services, drug and alcohol treatment etc39.
Conclusion
In conclusion high mortality and morbidity rate
among homeless population are caused by preventable
and treatable conditions but health care providers need
to be aware of the unique difficulties faced by this
subsection. There is need to improve accessibility and
availability of health services in order to serve homeless
population.
Medical care facilities for the homeless are
inadequate for a number of reasons: first, the
magnitude of homelessness, is under defined. Second
there is lack of studies on health problems of homeless
people in India. Third, the shortage of facilities and
the legal complications to provide them treatment.
Fourth, behavior of the homeless and the inability of
the providers to deal with such people. Fifth, in India
we do not have any proper existing health care services
and programmes for homeless, all that we have are
mostly supported by voluntary organizations.
Recommendations
In view of all these conditions, we suggest that
1. There is urgent need of proper definition and
development of proper methodology to have a
proper estimate of their number.
2. A national study to provide reliable data on health
problems and health care needs of homeless
people.
3. An attitude of dignity is essential when working
with people, who are homeless. Provide
motivational training to health providers (Health
Workers, Medical Officers, and Supervisors) to
be more sensitive towards this group.
4. Development of guideline to have a programme,
which should be accessible (outreach services),
affordable (free), comprehensive (both curative
and preventive component). It should include
mental health and substance abuse problems.
This programmes should also have preventive
component like screening for acute and chronic
health problems, immunization and special
services for women including family planning,
antenatal and perinatal care. The National Urban
Health Mission40 should look in to these aspects
and identifying and caring for homeless could be
one of the activities based incentives identified
for the Urban Social Health Activist (USHA).
5. Linking the programme with programmes like
National Rural Employment Guarantee (NREG)
Act41 which for rural area provides employment
opportunities. Effort should be taken to see that
homeless people can also avail this opportunity
and its counterpart in urban area needs to be
implemented.
6. Public health professionals also need to focus into
those social and economic issues, which are
compelling people to lead a life of homeless. They
also need to focus on operational aspects of
certain programmes (eg, RNTCP) which need to
be modified to include this particular group and
also to have effective control on the disease.
Patra S et al: Homelessness: A Hidden Public Health Problem
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Indian Journal of Public Health Vol.52 No.3 July - September, 2008
References
1. Tokle M. Some problems women are facing. Focus
on Gender.1994; 2(1): 37-8.
2. Breakey WR, Fischer PJ, Kramer M, Nestadt G,
Romanoski AJ, Ross A, Royall RM, Stine OC.
Health and mental health problems of homeless
men and women in Baltimore, JAMA 1989; (20):
10.
3. The Stewart B.McKinney, Homeless Assistance
Act of 1987, USA.
4. Govt. of India. Census of India, 2001.
5. Peressini T, McDonald L, Hulchanski D.
Estimating Homelessness: Towards A
Methodology for Counting The Homeless in
Canada, 1995, Canada Mortgage and Housing
Corporation Publishers.
6. Laska EM and Meisner M. A plant-capture
method for estimating the size of a population
from a single sample. Biometrics, 1993; 49:209-
20.
7. Gurgel CRQ, Fonseca JDC, Castañeda DN, Gill
G V, Cuevas LE. Capture-recapture to estimate
the number of street children in a city in Brazil.
Archives of Disease in Childhood 2004; 89:222-
224.
8. Plumb JD. Homelessness: reducing health
disparities [editorial]. Canadian Medical
Association Journal 2000; 163:172-3.
9. Wolch J, Dear M. Homelessness in an American
City. San Francisco: Jossey-Bass Publishers, 1-
43, 1993.
10. Nigam S. Street children of India- a glimpse. J
Health Manag. 1994; 7(1): 63-7.
11. Tiwari PA, Gulati N, Sethi GR, Mehra M. Why
do some boys run away from home? Indian J
Pediatr. 2002 ;69(5): 397-9.
12. Death among homeless-Atlanta. Morb Mortal
Wkly Rep.1987; 36:297-9.
13. Deaths among homeless persons-San Francisco,
1985-1990. Morb Mortal Wkly Rep. 1991;
40:877-80.
14. Hibbs JR, Benner L, Klugman L, Spencer R,
Macchia I, Mellinger AK, Fife D. Mortality in a
Cohort of Homeless Adults in Philadelphia. N
Engl J Med1994; 331(5):304-9
15. Hwang SW, Orav EJ, O’Connell JJ, Lebow JM,
Brennan TA. Causes of death in homeless adults
in Boston. Ann Intern Med. 1997; 126:625-8
16. Hwang SW. Mortality among Men Using
Homeless Shelters in Toronto, JAMA. 2000;
283:2152-2157
17. Ray SK, Biswas R, Kumar S, Chatterjee T, Misra
R, Lahiri SK. Reproductive health needs and care
seeking behaviour of pavement dwellers of
Calcutta. J. Indian Med Assoc. 2001; 99(3): 142-
3
18. Talukdar A, Roy K, Saha I, Mitra J, Detels R. Risk
Behaviors of Homeless Men in India: A Potential
Bridge Population for HIV Infection. AIDS Behav.
Dec 14, 2007. [Epub ahead of print]. [Online]
2008 [Cited 2008 April 30] Available from URL:
http://www.ncbi.nlm.nih.gov/pubmed/18080739
19. Bitro VO, Parra D, Facchini R, Bucchalla CM. HIV
infection, hepatitis B and C and syphilis in
homeless people, in the city of São Paulo, Brazil.
Rev Saude Publica. 2007 Dec; 41 Suppl 2:47-
56.
20. World Health Organization. TB Advocacy. A
Practical Guide. WHO/TB/98.239. Geneva:
WHO, 1998.
21. Ropers R, Boyer R. Homelessness as a health risk.
Alcohol, Health and Research World. 1987:38-
41.
22. Fleischman S, Farnham T. Chronic disease in the
homeless. In: Wood D, ed. Delivering Health Care
to Homeless Persons: The Diagnosis and
Management of Medical and Mental Health
Conditions. New York: Springer; 1992:81
23. Shaffer D, Caton, CLM, Runaway and homeless
youth in New York city: A report to the Ittleson
foundation, New York, Division of child
Psychiatry, New York State Psychiatric Institute
and Collumbia University, College of Physians
and surgeons; 1984
24. A Rapid Assessment of Drug Survey in India,
2002. Ministry of Social Justice and
empowerment and United Nations International
Patra S et al: Homelessness: A Hidden Public Health Problem
170
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Drug Control Programme. Regional Office for
South Asia. 2002.
25. Krammer CB, Gibran NS, Heimbach DM, Rivara
FP, Klein MB. Assault and Substance Abuse
Characterize Burn Injuries in Homeless Patients.
J Burn Care Res: 2008 Apr 2 [Epub ahead of
print] [Online] 2008 [Cited 2008 April 30]
Available from URL: http://www.ncbi.nlm.nih.gov/
pubmed/18388565
26. Banerjee SR. Physical abuse of street and slum
children of Calcutta. Indian Pediatrics 2001; 38:
1163-70
27. Rosenthal D, Mallett S.Involuntary sex
experienced by homeless young people: a public
health problem. Psychol Rep. 2003; 93(3 Pt 2):
1195-6
28. Kushel MB, Evans JL, Perry S, Robertson MJ,
Moss AR. No door to lock: victimization among
homeless and marginally housed persons. Arch
Intern Med. 2003; 163(20): 2492-9.
29. Rew L. Relationships of sexual abuse,
connectedness, and loneliness to perceived well
being in homeless youth. J Spec Pediatr Nurs.
2002; 7(2): 51-63.
30. Tyler KA, Cauce AM, Whitbeck L. Family risk
factors and prevalence of dissociative symptoms
among homeless and runaway youth. Child
Abuse Negl. 2004; 28(3):355-66.
31. Whitbeck LB, Hoyt DR, Johnson KD, Chen X.
Victimization and post traumatic stress disorder
among runaway and homeless adolescents.
Violence Vict. 2007;22(6):721-34
32. D. Hilfiker. Are we comfortable with
homelessness? JAMA. 1989; 262:1375-6
33. Avila MM, Gelberg L, Breakey W. Balancing Act:
Clinical Practices That Respond to the Needs of
Homeless People. The 1998 National Symposium
on Homelessness Research Department of
Housing and Urban Development and the U.S.
Department of Health and Human Services.
34. Health Needs Assessment Survey, 2000. Ashray
Adikar Abhiyan, IHBAS members of Narcotics
Anonymous and World Vision.
35. Survey Report, 2001, Ashray Adikar Abhiyan,
IHBAS members of Narcotics Anonymous and
World Vision.
36. Feldmann J, Middleman AB. Homeless
adolescents: common clinical concerns. Semin
Pediatr Infect Dis. 2003 ; 14(1): 6-11
37. A Report on the consultation ‘Space for the
Homeless and Marginalised in Delhi’ Organized
by ActionAid India Society and Slum &
Resettlement Wing, MCD under the aegis of the
Joint Apex Committee, on 25th July 2003, Friday
at Casurina Hall, India Habitat Centre, Lodhi
Road, New Delhihttp://www.delhiscience
forum.org/dmp2021/documents/A_NS.htm.
38. Health Care for the Homeless (HCH), Branch of
the Division of Special Populations/Bureau of
Primary Health Care (U.S. Department of Health
and Human Services, 1996).
39. Take charge programme (editorial) Philadelphia
Inquirer 1997, March 29. [Online] 2008 [Cited
2008 April 30] Available from URL : http://
www.annals.org/cgi/content/full/126/12/973
40. Urban Health Mission in three months: The
Hindu. 23rd February, 2008. [Online] 2008 [Cited
2008 April 30] Available from URL : http://
www.thehindu.com/2008/02/23/stories/
2008022360321700.htm
41. National Rural Employment Guarantee Act,
2005. [Online] 2008 [Cited 2008 April 30]
Available from URL : http://www.nrega.nic.in/
Patra S et al: Homelessness: A Hidden Public Health Problem
171
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Dear Editor,
Growing threat of HIV/AIDS to the people has
become a great concern of India and other developing
countries. The awareness of HIV/AIDS is the prevention
of the infection/ disease. Mass media such as Television,
Radio, Print Media, Hoardings, role plays etc. are the first
source of information and most effective modes of
communication between the media and the general
population where as health care providers are less source
of information1. It has been proved by many studies that
the main source of information for AIDS awareness in the
student is mass media 2-5. National AIDS Control
Organization (NACO) in collaboration with WHO and
other international agencies is dedicated and made many
efforts to develop the awareness among the people but
still prevalence is growing day by day.
In view of above, Hospital Administration, Sanjay
Gandhi Post Graduate Institute of Medical Sciences
(SGPGIMS) and Uttar Pradesh Hospital and Health
Administration Reforms Society (UPHHAR), Lucknow,
Uttar Pradesh, India intended to conduct a study of efforts
made by the government, NACO, NGOs etc to develop
the awareness through mass media for urban population
of Lucknow, Uttar Pradesh, during November – December
2005. The objectives were to find out the level of efforts
made through the mass media to develop the awareness
of HIV / AIDS amongst the general population by Best
Media Practices and to find out the level of contribution
made by hospital and the public places for HIV/AIDS
awareness.
Seven newspapers were considered; out of which 3
were English daily editions, 3 Hindi daily editions and 1
Urdu daily edition, all widely circulated in the city of
Lucknow. All these were scanned thoroughly for a period
of one month (8th November 2005 to 8th December 2005)
for the contents such as: general health awareness,
awareness about HIV / AIDS, health seminars /
programmes, central government health programmes and
miscellaneous (these include articles on rally’s, road shows,
surveys, camps, etc.) Of 143 contents of different health
related issues 52 (27%) were on HIDS/ HIV awareness. It
indicates that newspaper print media is contributing
reasonably adequate for HIV/AIDS awareness.
Six major pre-identified routes, which connect the
city to the railway stations, airport, bus stands covering
approx. 50 km. length network were covered to study
Letter to the Editor
HIV/ AIDS Awareness through Mass Media – the Measurement of
Efforts Made in an Urban Area of India
informative hoarding, banners & posters displayed
providing information about HIV/AIDS. The study
revealed that only 5% (7 out of 132) contribution is made
by the hoarding/ banner on road for HIV/ AIDS awareness
in comparison to other health related matters. Out of the
five hospitals visited, only two hospitals were found to be
actively involved in HIV/AIDS awareness through posters/
banners etc. This was quite an astonishing revelation
because hospitals are the main places where considerable
amount of awareness can be generated through posters,
banners and hoardings. Only 04% (2 out of 48) efforts
have been made by the hospitals to develop the AIDS/
HIV awareness in comparison to other health matters.
On the primary channel of All India Radio, 6
programs on AIDS were broadcasted in the month of
November 2005. In addition to this there was one phone–
in program on AIDS. 4 programs on AIDS were telecasted
by Doordarshan and only 1 on general health including
Kalyani I & II programs.
Traveling through various routes in Lucknow
revealed the fact that very few banners / hoardings are
devoted for the purpose of spreading AIDS awareness.
Out of the 6 routes covered (approx. 50 km. network area)
only 4 hoardings of AIDS were found. The number of
healthcare hoardings was unexpectedly low.
There is an urgent need to significantly scale-up
public health interventions in relation to HIV/AIDS
awareness that work (both in terms of coverage and
quality) to make a meaningful impact. While NGOs and
community-based organizations have a critical role to play
in implementing these interventions amongst the various
population groups, the government must shoulder the
overall responsibility for planning, coordinating,
mobilizing, and facilitating the various HIV/AIDS
prevention, care, and treatment services in the country.
References:
1. Ndlovu RJ, Sihlangu RH. Preferred source of
information on AIDS awareness among high school
students from selected school in Zimbabwe: Journal
of Advance Nursing, 1992 April; 17 (4): 507- 13.
2. Anochie L, Ikpeme E. AIDS awareness and
knowledge among primary school children in Port
Harcourt Metropolis: Niger Journal of Medicine,
2003 Jan – Mar; 12 (1); 27-31.
172
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
3. Maswanya E et al. Knowledge and attitude towards
AIDS among female college student in Nagasaki,
Japan, Health Education, Res. 2000 Feb; 15 (1): 5-
11.
4. Lihiri s et al. Women in 13 states have little
knowledge of AIDS: National Family Health Survey
Bulletin 1995 Oct; (2): 1-4.
5. Carducci A et al. AIDS related information, attitude
and behaviors among Italian male young people:
European Journal of Epidemiology 1995 Feb; 11
(1): 23-31.
Hem Chandra, K. Jamaluddin, L. Masih,
K. Faiyaz, N. Agarwal, D. Kumar
Hospital Administration, Sanjay Gandhi Post Graduate
Institute of Medical Sciences and Uttar Pradesh
Hospital and Health Administration Reforms Society,
Lucknow, Uttar Pradesh, India
Chandra H et al: HIV/ AIDS Awareness through Mass Media
Dear Editor,
Child health care in India focuses on the under-fives
under national programmes of ICDS and CSSM. Launch
of RCH programme in 1997, drew attention to the needs
of adolescents (10-19 years) also. But there remains a gap
in delivering health care to 5-10 years old children. This
age group is supposed to be addressed by the school health
programme, which in India is very inadequate, without
follow-up or accountability.
In the union territory of Pondicherry, one of the top
achievers of human development in the country having
low infant and child mortality rates 1 we compared the
nutritional status of 5-10 year old children with under-
fives attending out patient clinic of Primary Health Centre
(PHC), Mettupalayam, in Pondicherry town. Weight for
age was used to measure undernutrition. Weights of all
children less than 10 years was measured by the physicians
using a baby weighing machine (pan type) for infants and
a personal weighing scale for others in the months of
August and September 2007. Each child was considered
once in spite of multiple visits. According to IAP
classification, underweight was measured as percentage
of the median of NCHS standard.
Undernutrition in 5-10 Year Olds: Experiences
from a PHC in Pondicherry
The total number of children observed was 518. This
being a primary care centre, most children in both age
groups had minor ailments. We observed that a higher
proportion (58%) of 5-10 year old children were
malnourished as compared to under-fives (50%), though
not statistically significant. However, significantly greater
proportion of children in 5-10 years had severe
malnutrition i.e., < 60% of the expected weight for age
(χ2 = 10.94, p = 0.00094).
The deprivation in nutrition will have long-
term implications such as poorer work capacity
and reproductive performance in adulthood2. But,
this population is not representative of the children
in the community as this was hospital based. So,
this study needs to be extended to the community
to assess the overall scenario. We recommend
continuum of care from under-five through 5-10
years to the adolescents by strengthening the
school health services.
References:
1. Profile of the Union Territory of Pondicherry. http://
ncw.nic.in/pdfreports/Gender%20 Profile Pondi-
cherry.pdf (last accessed on 8.5.08)
2. Kliegman: Nelson textbook of pediatrics, 18th ed.
Saunders: Philadelphia; 2007. p 228.
S. Sarkar1, S. Ananthakrishnan2
1Dept. of Community Medicine, 2Dept. of Paediatrics;
PKMC&RI, Puducherry, India
Correspondence: sarkarsonaligh@gmail.com
Table 1: Undernutrition in 5-10 year olds as
compared to under-fives
Age groups % of expected weight for age
>80% 71-80% 61-70% <60% Total
F 78(49.4) 61(38.6) 16(10.1) 3(1.9) 158
<5 yrs M 111(50) 68(30.6) 38(17.1) 5(2.3) 222
Total 189(49.8) 129(33.9) 54(14.2) 8(2.1) 380
F 31(43.1) 20(27.8) 14(19.4) 7(9.7) 72
5-10 yrs M 27(40.9) 18(27.3) 16(24.2) 5(7.6) 66
Total 58(42.1) 38(27.5) 30(21.7) 12(8.7) 138
Figures in parentheses are row percentages
