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Year : 2013 | Volume : 1 | Issue : 1 | Page : 30 - 33  


Short Communications
A Comparative Study of Morbidity Pattern among Children of 0-6 years in ICDS and non ICDS Area

Saurabh R. Kubde1, Prashant R. Kokiwar2

1Director, Kubde Children Hospital, Nagpur, Maharashtra. 2Professor and Head, Department of Community Medicine, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad

Summary

Government of India (GOI) introduced in 1975, its most ambitious and comprehensive plan to increase child survival rates among the poorest and enhance the health, nutrition and learning opportunities of preschool children and their mothers through the Integrated Child Development Services (ICDS) scheme. The ICDS scheme can have positive impact on the health status of the children. The objective of the study is to compare the morbidity pattern among children of 0-6 years in ICDS and non ICDS area. The present cross sectional study with comparison group was planned to compare the health status of 0-6 years children in ICDS and non ICDS urban slums of Nagpur city. Morbidity was assessed for recent illness in last 90 days prior to the visit. Statistical test used were Z test for difference between two proportions and Z test for difference between two means. There were total 239 and 321 morbid conditions found during study in ICDS and non ICDS areas respectively. Anemia was most frequent morbid condition in both the areas. Mean morbid condition per child in ICDS and non ICDS areas was 0.85 + 1.01 and 1.14 + 1.2 respectively. No morbid condition was in 132 (47.2%) children in ICDS and 110 (39.3%) children in non ICDS area. Thus we can say that the overall health status of children of ICDS area is better off (though not very good) when compared with children from non ICDS areas.

Key words: health status, ICDS, morbidity

Corresponding Author: Dr. Saurabh R. Kubde, Director, Kubde Children Hospital, Nagpur, Maharashtra. Email: srkubde74@gmail.com


Introduction:

It is the early childhood that the foundation for physical, psychological, and social development is laid and if an appropriate range of services can be provided, particularly to the weaker and vulnerable sections of the community, problems such as infant mortality, physical handicaps, malnutrition can be overcome. Therefore the organization of early childhood services was thought to be an investment in the future economic and social progess of the country. [1]

A majority of India’s children live in impoverished economic, social and environmental conditions which impede their physical and mental development. As a response to the unmet needs of this vast and vulnerable population, the Government of India (GOI) introduced in 1975, its most ambitious and comprehensive plan to increase child survival rates among the poorest and enhance the health, nutrition and learning opportunities of preschool children and their mothers through the Integrated Child Development Services (ICDS) scheme. [2]

New ICDS is effective in 5659 community development blocks and major urban slums throughout the country. As against 2.27 crore beneficiaries until March 1997, there were 3.4 crore beneficiaries in April 2001. In 2006 the scheme reached out to about 95 lakh expectant and nursing mothers and 244.92 lakh pre-school children and 562.18 lakh beneficiaries are getting supplementary nutrition. 10.53 lakh Anganwadi centres (AWCs) are operational and up to 14 lakhs AWCs are planned. [3]

Urban population in India is increasing day by day. Rapid industrialization has resulted in phenomenal growth of urban slum settlements in many big cities of India in the recent post. [4] In India, slum dwellers comprise 25% of the total population of the large metropolitan cities. The growth and development of slum children is jeopardized by economic poverty and low social status because of their mobility, diversity and poor sanitation. Studies have shown that 85% of the preschoolers are undernourished. [5] The ICDS scheme can have positive impact on the health status of the children. With this background, present study was undertaken to compare the morbidity pattern among children of 0 – 6 years in ICDS and non ICDS area.

Methods:

The present cross sectional study with comparison group was planned to compare the health status of 0-6 years children in ICDS and non ICDS urban slums of Nagpur city. Out of the two urban projects, urban ICDS project II, Gandhi Nagar was randomly selected by toss. Out of the four zones working under this project one i.e. Shivaji Nagar zone was randomly selected. This zone includes 25 Anganwadi centres. Out of these 25 Anganwadi centres, one Anganwadi centre Bhuteshwar Nagar was randomly selected for the pilot study. Non ICDS area selected was Gayatri Nagar, an urban slum which is nearby to the selected ICDS area. In the ICDS area, all the children who were enrolled in Anganwadi centre were included in the study. Whereas in non ICDS area, equal number of 0-6 years age group children were included in the study. A pilot study was carried out with the purpose of testing proforma and estimation of sample size.

The sample size was estimated depending on the prevalence of anemia obtained in both ICDS and non ICDS areas in the pilot study. During pilot study the prevalence of anemia in both ICDS and non ICDS areas was observed as 45.21% and 58.26% respectively. As the study design is cross sectional study with comparison group, sample size was estimated by the following formula. [6]

N = {Z1-α √[2P(1-P)] + Z1-β √[P1(1-P1) + P2(1-P2)]}

                                       (P1-P2)2

P1 = Prevalence of anemia in ICDS area = 45.21%

P2 = Prevalence of anemia in non ICDS area = 58.26%

P = (P1 + P2) / 2

So at 5% level of significance, the sample size (N) was estimated to be 245. Finally total number of study subjects included was 280 from each i.e. for ICDS area 115 and 165 from Bhuteshwar Nagar and Shivaji Nagar Anaganwadi centres respectively and for non ICDS area, 115 and 165 from Gayatri Nagar and Nandaji Nagar respectively. The official permission for conduction of the study in ICDS areas was obtained from Child Development Project Officer, Gandhi Nagar, Nagpur. In ICDS areas children were traced out in their homes while in non ICDS areas house to house survey was carried out to assess the health and nutritional status. The purpose of the study was explained to the parents. The background information was recorded as per the predesigned proforma by interviewing the mother. The stated age of the child was critically assessed and only few mothers required help to recall the birth date with the help of local calendar requiring important events and festivals in each month. In the clinical examination of the child, actual morbid conditions and signs of nutritional deficiency conditions were noted. Morbidity was assessed for recent illness in last 90 days prior to the visit. This was done by describing the symptoms of common childhood illnesses like acute respiratory tract infections, worm infestations, diarrhoeas, malaria, jaundice, dental caries, skin infections and other ear morbidities in local language. All the children who were found to be suffering from minor ailments were given treatment. Statistical test used were chi square test, Z test for difference between two proportions and Z test for difference between two means.

Results: Table 1 shows distribution of morbid conditions among the study subjects in ICDS and non ICDS area. There were total 239 and 321 morbid conditions found during study in ICDS and non ICDS areas respectively. Anemia was most frequent morbid condition in both the areas. (48.1% in ICDS and 48% in non ICDS area). Mean morbid condition per child in ICDS and non ICDS areas was 0.85 + 1.01 and 1.14 + 1.2 respectively. This difference in means was statistically significant. (Z = 3.09, p < 0.001)

Table 2 shows distribution of study subjects according to number of morbid conditions in ICDS and non ICDS areas. No morbid condition was in 132 (47.2%) children in ICDS and 110 (39.3%) children in non ICDS area. Majority of the children were found with one morbid condition i.e. 87 (31.1%) children in ICDS and 78 (27.8%) children in non ICDS area. Children with four morbid conditions were found more in non ICDS (5%) than that of ICDS (2.1%) areas.

Table 3 shows various nutritional deficiency conditions noted during the course of clinical examination of children. Ten children in ICDS area (3.6%) and 23 children (8.2%) in non ICDS area had one or more than one signs of protein energy malnutrition (PEM). This difference was statistically significant (p < 0.05). Common signs found were hair changes and muscle wasting. Eight children (2.9%) in ICDS area and 20 children (7.1%) in non ICDS area had signs of vitamin A deficiency like conjunctival xerosis or Bitot’s spot. This difference was statistically significant (p < 0.05). Signs of vitamin B complex deficiency like angular stomatitis, cheilosis and glositis were observed in 16 children (5.7%) in ICDS area and 23 children (8.2%) in non ICDS area. When statistically tested this difference was not significant (p > 0.05).

 


Table 1: Distribution of morbid conditions found during study in ICDS and non ICDS areas.

Morbid condition                                               ICDS                                      NON ICDS

Respiratory infections                                      27 (11.3)*                             22 (6.8)

Acute nasopharyngitis                                           21                                           14

Acute bronchitis                                                    06                                           07

Measles                                                                00                                           01

Worm infestation                                               22 (9.3)                                  26 (8.1)

Diarrhoeal diseases                                           12 (5.0)                                  18 (5.6)

Diarrhea with dehydration                                       02                                           05

Diarrhea with no dehydration                                   10                                           13

Vitamin A deficiency                                            09 (3.8)                                  22 (6.8)

Conjunctival xerosis                                                 07                                           18

Bitot’s spot                                                              02                                           04

Vitamin B complex deficiency                              16 (6.7)                                  23 (7.2)

Angular stomatitis                                                    14                                           18

Glossitis                                                                  02                                           05

Protein Energy Malnutrition                                 12 (5.0)                                  28 (8.8)

Sparce hairs                                                            08                                           19

Muscle wasting                                                         04                                           06

Dermatosis                                                              00                                           03

Anemia                                                                 115 (48.1)                             154 (48.0)

Conjunctival pallor                                                   114                                         151

Koilonychias                                                             001                                         003

Dental caries                                                          02 (0.8)                                  01 (0.3)

Malaria                                                                    00                                           01 (0.3)

Jaundice                                                                  01 (0.4)                                  00

 Some children had more than one morbid condition.

Mean morbidity per children: ICDS area: 0.85; non ICDS area: 1.14 (Z=3.09, p < 0.001).

*Figures in the parentheses indicate percentages

 

Table 2: Distribution of study subjects according to number of morbid conditions in ICDS and non ICDS areas.

 

 

No. of                                   ICDS area       non-ICDS area

morbid

conditions                                                                            

No morbidity                        132 (47.2)*           110 (39.3)

One morbid condition            087 (31.1)             078 (27.8)

Two morbid conditions           037 (13.2)             047 (16.8)

Three morbid conditions         018 (06.4)             031 (11.1)

Four morbid conditions           006 (02.1)             014 (05.0)

Total                                      280 (100)              280 (100)

*Figures in the parentheses indicate percentages

Thus all nutritional deficiency diseases were found in higher magnitude in non ICDS areas than that in ICDS areas.

 

Table 3: Nutritional deficiency conditions by clinical examination in ICDS and non ICDS areas.

 

Deficiency            

conditions             ICDS area             non ICDS area     Z

Anemia                  114 (40.7)*           151 (53.9)     p< 0.001

PEM                       010 (03.6)             023 (08.2)     p< 0.05

Vitamin A

deficiency             008 (02.9)             020 (07.1)     p< 0.05

Vitamin B

complex

deficiency             016 (05.7)             023 (08.2)     p> 0.05

*Figures in the parentheses indicate percentages

 

Discussion: The present cross sectional study with comparison group was conducted in four urban slums of Nagpur city. Two of which were ICDS areas while other two were non ICDS areas. Study included two hundred and eighty children from each group. Higher morbidities are seen in children of non ICDS group than that of ICDS group. Children free from any morbid conditions were higher in ICDS (47.2%) than in non ICDS (39.3%). Nutrition Bureau, Public Health Institute, Nagpur [7] in their study among urban ICDS project, Nagpur reported that 73.8% children were normal i.e. free from any morbid condition. Comparatively higher morbidities were found in the present study. Lal S [8] have reported that whatever gains obtained by the package of services provided through ICDS gets nullified by recurrent infections such as diarrhoeas, fever, respiratory and skin infections.

Higher prevalence rates of infections are also reported by Motghare DD et al. [9] He found that prevalence of respiratory infections, worm infestations and diarrhoeal diseases as 9.79%, 9.44% and 4.19% respectively. Kolhe RD [10] also reported higher prevalence of morbidities in ICDS group than that in non ICDS group. Bansal R [11] observed higher prevalence of morbidities among under five children. The infections observed were respiratory infections (41.3%), gastrointestinal infections (31.7%), skin diseases (19%), injuries (17.5%), eye infections (14.3%), burns (11.1%), fever (4.5%) and pediculosis (6.3%) respectively. Rao S et al [4] also reported the higher prevalence of morbid condition in preschool children particularly in rainy season and was associated with wasting but not stunting. Gastrointestinal illnesses and fever contributed 50% of total morbidity days.

Instead of taking isolated clinical signs to diagnose deficiency of a particular nutrient, it is most helpful, if the signs are grouped together to form a pattern. The more numerous the signs present in one group, the more probable the diagnosis of deficiency of particular nutrient (Jelliffe, 1966). [12] The concept of “key sign” was based on the association of a certain sign with a given nutrient deficiency such as angular stomatitis and riboflavin deficiency. Such concept is no longer held true because the signs lack specificity and the diet of the community is unlikely to be deficient in none nutrient only. The interpretation of clinical signs can best be made by “grouping of signs” which has been commonly found to from a pattern associated with the deficiency of a particular nutrient. In the present study, the grouping of signs was made. World Health Organization [13] reported prevalence of anemia in preschool children of developing countries as 51%. Nutrition Bureau, Public Health Institute, Nagpur [7] in the study among ICDS project areas, Nagpur observed sparse hairs in 0.5%, discolored hairs in 0.7%, emaciation in 4.1%, marasmus in 0.2%, conjunctival xerosis and bitot’s in 2.5%, anemia in 5.7%, signs of vitamin B complex deficiency in 2.7%. Bansal R [11] in his study observed the prevalence of nutritional anemia as 77.8%, vitamin A deficiency as 55.6%, vitamin B complex deficiency as 30.2% and PEM as 81%. Dwiwedi SN et al [14] reported that by clinical examination the prevalence of PEM, vitamin A, vitamin B complex deficiency and anemia in preschool children were 63.4%, 23.4%, 16.2% and 7.2% respectively. Fakhir S et al [15] reported the prevalence of xerophthalmia in under five children as 10%. Arya A et al [16] reported that clinically various nutritional deficiencies were as signs of PEM in 9.5%, signs of vitamin A deficiency in 6%, vitamin B complex deficiency in 8% and anemia in 16% children. Khandait DW [17] observed prevalence of xerophthalmia in undersix children as 8.7%. Similar findings have been reported by Garg SK et al [18] and Avadheshkumar et al. [7] The mothers in the present study were asked to mention any morbidity their child had suffered in the past 90 days or not. If yes, they were asked to describe it. During this data collection process, there may be recall bias. And this is the limitation of the study. But every effort was made to explain the mother regarding the morbidities, to overcome this limitation.

Thus from the present study we can say that the overall health status as observed from study of morbidity pattern among children of ICDS area is better off (though not very good) when compared with children from non ICDS areas. Thus there is need of not only expanding the ICDS services all over but also it is very important that the Anganwadi workers be trained properly and motivated so that they can educate mothers.

References:

  1. All India Institute of Medical Sciences. Integrated child development services. Information document (TCHN) AIIMS, New Delhi, 1983.
  2. Sadka NL. ICDS integrated child development services in India. UNICEF (1984), New Delhi.
  3. Kishore. Integrated Child Development Service (ICDS) Scheme. In: J. Kishore’s National Health Programmes of India. 9th Ed. New Delhi: Century Publications;2011:409
  4. Rao S, Joshi SB, Kelkar RS. Changes in nutritional status and morbidity over time among preschool children from slums in Pune, India. Indian Pediatr 2000;37(10):1060-71
  5. Shrivastava MM, Patel NV. Nutritional status of tribal and urban slum preschool children (3-4 years). Indian Pediatr 1997;29(12):1559-63
  6. Zodpey SP, Ughade SM. Module of Workshop on Sample Size Considerations in Medical Research, Nagpur 1999: p-76
  7. Report of Nutritional Bureau. Public Health Institute, Nagpur 1990
  8. Lal S. field assessment of impact of package of interventions on the incidence of severe malnutrition. Indian J Prev and Social Med 1981;12:144
  9. Malin AS, Stones RW. Nutritional anemia in the urban poor – a communit based study of underfive in an Indian slum. J Trop Pediatr 1988;34(5):257-59
  10. Kolhe RD. Study of health status of preschool children pregnant and lactating women in ICDS and non ICDS tribal block, Dharani. Thesis for MD (PSM), Nagpur, 1988
  11. Bansal R. Heatlh profile of underfive migrant tribal children. Ind Med Gazette 1992;16(5):137-38
  12. Jelliffee DB. The assessment of nutritional status of the community. World Health Organization. Monograph series 1996; 53.
  13. DeMacyer EM. Preventing and controlling iron deficiency anemia through primary health care. A guide for health administrators and programme managers. World Health Organization, Geneva 1989.
  14. Dwivedi SN, Banerjee N, Yadav OP. Malnutrition among children in an urban Indian slum and its association. Indian J Maternal and Child Health 1992;3(3):79-81
  15. Fakhir S, Shrivastava I, Ahmad P, Husan SS. Prevalence of xerophthalmia in preschool children in an urban slum. Indian Pediatr 1993;30:668-70
  16. Arya A, Rohini Devi. Pattern of nutritional deficiencies in preschool children as influenced by family income. Ind J Nutr Dietet 1997;34:185-87
  17. Khandait DW. A study of prevalence and some epidemiological factors associated with xerophthalmia in under six children in urban health centre area, Nagpur. Thesis for MD (PSM), Government Medical College, Nagpur University, Nagpur 1996
  18. Garg SK, Singh JV, Bhatanagar M, Chopra H. Nutritional status of children (1 – 6 years) in slums of Ghaziabad city. Indian J Comm Med 1997;22(2):70-73
  19. Avadheshkumar, Mehra M, Badhan SK, Sandansingh. Xerophthalmia in urban slum children of Delhi. Indian J Comm Med 1998;23(4): 169-71

 

Source of support: Nil. Conflict of interest: Not Declared





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