|Year : 2013 | Volume
| Issue : 2 | Page : 96-101
Burden of health morbidities in under-fives in urban slum areas
Hanmanta V Wadgave
Department of Public Health, Zilla Parishad Solapur, Solapur, Maharashtra, India
|Date of Web Publication||21-May-2013|
Hanmanta V Wadgave
33, Furde Res-I, Behind ITI College, Near Mahalaxmi Mangal
Source of Support: None, Conflict of Interest: None
Background: About 200 million people in India are living in urban slum areas without basic health facilities. Poor environmental conditions, compounded by poverty, malnutrition, and deficient health-care, make the children and women susceptible to a host of infectious diseases.
Research Question: What is the burden of health morbidities in under-fives in urban slum area?
Aim and Objectives: Study of burden of health morbidities in under-fives in urban slum area.
Materials and Methods: Community based cross-sectional study. Conducted in the slum area covered by the field practice area of Urban Health Centre, Dr. V. M. Medical College, Solapur during the period of January 2007 to April 2007. A total of 420 under-five children were selected from six slum areas. Seventy under-fives from each slum were selected by simple random sampling.
Results: Out of total 420 under-fives 238 (56.67%) were males and 182 (43.33%) were females. The average age of the under-fives was 32.9717.02 months. 84.76% children were suffered from one or more than one morbidities. Overall health morbidities were significantly more in female. The most common health morbidity observed was protein energy malnutrition (PEM)(67.62%), followed by acute respiratory infection (ARI)170 (40.48%), pyrexia of unknown origin (PUO)85 (20.24%), acute diarrheal disease 77 (18.33%), and worm infection 57 (13.57%). PEM, ARIs, PUO, and acute diarrhea were common in female while, worm infection, skin infection, and injuries were more in male children.
Conclusion: Maximum (84.76%) under-fives in urban areas suffered from one or more health morbidities. This intensifies the need of comprehensive and need based planning of health policies for slum area.
Keywords: Acute respiratory infections, lack of service facility, protein energy malnutrition, slum
|How to cite this article:|
Wadgave HV. Burden of health morbidities in under-fives in urban slum areas. J NTR Univ Health Sci 2013;2:96-101
| Introduction|| |
The value of knowing the morbidity pattern of childhood diseases is great, particularly in the developing countries like India, where the planning of health program must be geared to obtain the maximum development of healthy nation.Globally, India has the largest population of under-5s (127 million), and the greatest number of under-5 deaths (2.1 million) in 2006. Of the 19 million low-birth-weight infants born in South Asia, 8.3 million are in India. More than 30% of India's under-5 deaths are caused by pneumonia. Diarrheal diseases remain a serious threat to child survival with an estimated 9% of children suffering from this condition in India. , About 200 million people in India are living in urban slum areas without basic health facilities. Around 60% of them are women and children. Poor environmental conditions, compounded by poverty, malnutrition, and deficient health-care, make them susceptible to a host of infectious diseases. Children are the worst victims of these circumstances.  Grover et al. found that 53.7% of the children from resettlement colony of East Delhi were suffering from some form of illness. Acute respiratory infections (ARI) was most common cause (16.01%) followed by diarrhea (10.2%).  While, in other study by Panda et al. in Ludhiana slum found 61.6% cases of diarrhea, 5.1% cases of ARI/feverand 19% of the cases suffering from severe malnutrition.  Gladstone et al. noted 58.3% of under-3 children in an Indian slum were of respiratory infections, 18.4% gastrointestinalinfections,13.9% of discharge from ear, nose, and localized infections without fever and 6.3% children suffer fromnon-infectious morbidity such as congenital anomalies, anemia, andmalnutrition. 
Thus, the varied morbidities in the under-fives in slum areas intensifies the great need to study the distribution of health morbidities in under-five children forneed based planning within available resources of health-care.
| Aim and Objective|| |
To study the burden of health morbidities in under-fives in urban slum areas.
| Materials and Methods|| |
Type of study
Community based cross-sectional study.
Study was conducted in the slum area covered by the field practice area of Urban Health Centre (UHC), Dr. V. M. Medical College, Solapur during the period of January2007 to April2007.
Four hundred and twenty under-five children.
Sample size estimation was carried out by using the formula 4pq/L 2 where, p = prevalence of positive character, i.e., prevalence, q = 100-p and L = allowable error at 5%. Panda et al. noted that 66.7% of under-five children in Ludhiana suffered from some form of illnesses. Considering the reference value noted by Panda et al., i.e., 66.7%, the sample size calculated was 355 but total 420 under-five children were taken for the study.
There were a total six slum areas under UHC Solapur and the population of each slum varies from 4000 to 6000 people. It was decided to cover all slums in the study to reduce the selection bias. Seventy under-fives from each slum were selected by simple random sampling. Necessary information was taken from the close relatives of the subject, i.e., parents or grandparents. Informal consent of parents was taken by explaining the purpose of study. The history of preceding 1 month of the subject was taken for the study. The period of 1 month was kept as minimum so as to reduce recall bias. There are total nine anganwadis, two private general practitioners, and one UHC situated in the study area. However, for the services of maternal and child health, UHC is the main source. Health seeking behavior of the study population was also taken into consideration while quoting the recommendations. Data was collected in prescribed and pre-tested pro-forma. Clinical examination and measurements were taken personally in house to house visit. Gradation of malnutrition was carried out using the Indian Academy of Pediatrics classification. All data analyzed and presented in the form of percentages. Chi-square test was applied wherever applicable.
| Results|| |
In the present study, 420 under-five children were studied. Out of 420 under-fives 238 (56.67%) were males and 182 (43.33%) were females. The average age of the under-fives was 32.97 ± 17.02 months as shown in [Table 1]. Out of 420 under-five children 356 (84.76%) children were suffered from one or more than one morbidities. Overall health morbidities were significantly more in female as compared to male under-fives, i.e., 163 (89.56%) and 193 (81.09%) respectively (P < 0.017) [Table 2].
[Table 3] shows the most common health morbidity in the present study was protein energy malnutrition (PEM) observed in 284 (67.62%) under-fives. Followed by ARI170 (40.48%), pyrexia of unknown origin (PUO) 85 (20.24%), acute diarrheal disease 77 (18.33%) and worm infection in 57 (13.57%) under-fives. Maximum under-fives of PEM (43.66%) and skin infections (61.54%) were in the age group 37-60 months. While ARI (50.68%) and PUO (60%) were more in the age group 13-36 months, acute diarrheal disease was more (58.44%) below 2 years of age [Table 4]. Worm infection, skin infections, and injuries were more in male children as compared to female children but the relation was not statistically significant. While PEM, ARI, PUO, acute diarrheal diseases were more in female children as shown in [Table 5].
|Table 3: Prevalence of Health Morbidities Among Study Population (n = 420)*|
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|Table 4: Age Wise Distribution of Health Morbidities Among Study Population|
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|Table 5: Gender Wise Distribution of Health Morbidities Among Study Population|
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Maximum 76% of the patients prefer the UHC for maternal and child health services, 18% prefer private practitioners,and 6% in anganwadi.
| Discussion|| |
In the study of 420 under-fives, 56.67% were males and 43.33% were females. Panda et al. noted 51% male and 49% female under-fives in the study of Ludhiana. The average age of the children under study was 32.97 ± 17.02 months. While, Shahidullah et al.  found the mean age of the children who suffer from infectious disease was between 2 and 3 years old.
In the present study, 84.76% children were suffered from one or more than one morbidities. However, Grover et al.  and Panda et al.  observed that only 53.7% and 66.7% under-fives respectively suffered from health morbidities as compared to the present study (84.76%).This high burden of health morbidity in the present study indicates the vulnerability of the under-fives residing at slums as well as it intensifies great need to formulate the policies to tackle these issues.
Health morbidities were significantly more in female children as compared to male children (89.56% vs. 81.09%, P < 0.017). Similar finding was noted by Panda et al. (female-68.1% vs.male 65.3%). However, Grover et al. found opposite finding as compared to present study where health morbidities were significantly higher in boys as compared to girls (63.4% vs. 26.4%, P < 0.01). Even though the health morbidities were more in girls found in community studies/survey but the attendance to health facilities of girl child was less as compared to male child observed by Verma et al. where 59.89% under-five attendance of primary health center was of male child as compared to female (40.11%). Obi  noted similar picture in the Nigerian hospital where ratio of male to female admission was 3:2. Inspite of high morbidity and mortality found in girl child, , male children were preferably protected from health-care divulging the girl child from their rights of child care. So there is a great need to address this issue of gender discrimination and child rights.
67.62% of the children in the present study were malnourished which comprised of 24.76%, 30%, and 13.86% of children with grade I, II and III and IV degrees of PEM, respectively. Similar finding was noted by Bhat et al. (60.45%) and Ray et al. (69.43%). However, very high percentage of malnutrition was found in Ludhiana slums as compared to the present study (87.4% vs. 67.62%). 
The percentage of severe malnutrition noted by Panda et al. (19%), Ray et al. (16%) and Devdas et al. (16%) was comparable to the present study (13.86%). However,the percentage noted by Bhat et al. was less as compared to the present study (6.34% vs.13.86%). ARI was the second most common (40.48%) morbidity found in the present study. However, low percentage of ARI was observed by Verma et al.,  Devdas et al.,  Grover et al.,  and Panda et al. where, the percentage of respiratory infection was 29.4%, 33%, 16.01%, and 5.1% respectively. Very high percentage (55.7%) of respiratory infections was noted by Hanspal et al. This variation in the percentages may be due to the variation in the study set-up, i.e., hospital based or community based and variation in the definition of ARIs under study. 20.24% of the under-fives in the present study suffered from PUO. Similar findings were also noted by Devdas et al. (17%) and Kumar Datta et al. (20.8%). However, lower figures were observed by Grover et al. (7.3%), Panda et al.  (5.1%), Verma et al. (10.5%) and Hanspal et al. (10.6%). In the present study, 18.33% under-fives suffered from acute diarrhea. Similar percentage was noted by Verma et al. (15.5%), Devdas et al. (11%), Grover et al. (10.2%) but Hanspal et al.,  Obi,  and Panda et al. found high percentage of acute diarrhea, i.e.,29.2%, 27.3%, and 61.6% respectively.Worm infection was observed in 13.57% of under-fives. However,Grover et al. found 7.3% under-fives with worm infection. Skin infections were found in 6.19% of under-fives. Verma et al.,  Grover et al.,  and Hanspal et al. noted skin problems and infections of subcutaneous tissue in 12.5%, 9.2%, and 2.7% children respectively. This varied percentage of skin problems may be due to the variation in the case of definition of skin infections. Chronic illnesses such as tuberculosis, asthma, HIV/AIDS, nephritis, and measles were found in 5.24% under-fives. This was also agreed by Verma et al. (4.5%) and Kumar Datta et al. (4.36%). This indicates the burden of chronic illnesses among the under-fives in slum area. In the present study, injuries were found in 4.52% under-fives. Similar finding was observed by Verma et al. (4.5%) and Grover et al. (2.4%).
By analyzing the morbidity by age,PEM was increased with increasing age. Similar finding was observed by Bhat et al. ARI and acute diarrhea was more common below 2 years of age and constitutes about 45.49% and 58.44% of total ARI and acute diarrhea cases respectively. Similar finding was noted by Obi  where, the percentage of ARI and gastroenteritis below 2 years was 57.49% and 60.44% respectively. Devdas et al. also found 48.06% cases of respiratory tract infections and 73.33% cases of acute gastroenteritis below 2 years similar to present study. The maximum distribution of ARI and diarrhea cases below 2 years may be due to the poor hygiene maintained during weaning practices that drags the child in the cycle of attacks of acute diarrhea and ARI. PUO in under-fives was common below 2 years (52.94%). Similarly Devdas et al. observed 52.23% PUO cases below 2 years of age. Skin infections were common after 2 years of age, which was also agreed by Verma et al. In the present study, 42.11% injuries observed in 37-60 months age group. This finding was also agreed by Nath et al. where, 38.9% injuries occurred in the age group of 49-60 months. This may be explained, as it is a school going age in which there are more chances of exposure to surrounding environment vulnerable to injuries.
PEM, ARI, acute diarrhea, and chronic illnesses were more in female children while, worm infections, skin infections, and injuries were more common in male children. Similarly, malnutrition and acute diarrhea was significantly more in female children observed by Panda et al. Bhat et al. also noted higher prevalence of malnutrition in female as compared to male children (73.58% vs. 50.89%, P < 0.001).Grover et al. and Devdas et al. found the high percentage of ARI and acute diarrhea in male children as compared to female children and this was a different finding than the present study. Worm infection, skin infections, and injuries were more common in male children was also agreed by Grover et al. Injuries were significantly more on male children which was noted by Nath et al. where 70.3% injured under-fives were males. Better child rearing among male children is noticeable nature in our society. This preferential treatment was also confirmed in the present study where malnutrition, ARI, acute diarrhea was more in female children as compared to male children and likely to continue unless a dramatic change occurs in our present social set-up. 
| Conclusion|| |
Maximum (84.76%) under-fives in urban areas suffered from one or more health morbidities. PEM was the most common health morbidity found in 67.62% under-fives followed by ARI (40.48%), PUO (20.24%), acute diarrheal disease (18.33%). 13.86% of the under-fives in the study area suffered from severe type of malnutrition.
| Recommendation|| |
- Comprehensive and need based planning of health polices for slums to tackle the various morbidities including adequate manpower, drugs and other diagnostics health facilities.
- Special program of control of malnutrition should be there in slum area like Anganwadi level Child Development Centers for grade-1 and 2 children and Child Treatment Centers for grade-3 and 4 children,which will provide the nutritious diet, drugs, and expert medical care to the malnourished children and training to the parents about the child care practices. This, at present is not included in malnutrition control program of the slums.
- More focus on counseling of the parents and care takers through anganwadi workers/health workers on cultivation of healthy hygiene practices like washing hand before meal and after toilet, keeping clean house free from cracks and crevices, use of sanitary latrine for defecation etc. This will reduce acute diarrheal disease and worm infections.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]