Indian Pediatrics 2001; 38: 1009-1017  

A Comprehensive Study of Morbidity in School Age Children

Shanthi Ananthakrishnan, S.P. Pani*, P. Nalini

From the Department of Pediatrics, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India and *Vector Control Research Center, Indian Council of Medical Research, Pondicherry, India.

Correspondence to: Dr. Shanthi Ananthakrishnan, Type 5/1, Dhanvantri Nagar, Pondicherry 605 006, India.

Manuscript received: November 2, 2000;Initial review completed: December 13, 2000;Revision accepted: March 2, 2001.

School age children (5-15 years) have not received as much attention from health providers/planners as the under fives. In an international workshop at Kentucky, USA in 1994, it was agreed that there was a dearth of information on the health status of school age children from developing countries parti-cularly at the community level(1). In India, several studies have been carried out on the health status of school age children. These have largely been quantitative and the reported morbidity included malnutrition (10.0-98.0%), dental ailments (4.0-70.0%), worm infestation (2.0-30.0%), skin diseases (5.0-10.0%), eye diseases (4.0-8.0%), and anemia (4.0-15.0%)(2-10), However, data on the commu-nity’s perception about these morbidities are inadequate. It is now being increasingly recognized that proper understanding of the community’s view point of any health problem contributes significantly towards formulating and implementing strategies that improve their health. Therefore, qualitative research methods, which bring out the community’s perception of any issue, should form an integral part of investigation of morbidity. With this background, this study was conducted to evaluate the extent and pattern of health status of school age children applying both qualitative and quantitative methods.

Subjects and Methods

Study Area

The study was carried out in Kedar, a village in Tamil Nadu (population 3,000). The objectives of the study were explained to and informed consent was obtained from the village leader, parents, teachers and children. Most of the villagers are either landless agricultural labourers or weavers and are socioeconomically backward with an average per-capita income of Rs. 2,201 ± 36 (US $50 ± 0.7) per annum. The village has two government schools - a primary school and a high school with a middle school section. There is a government sponsored mid-day meal scheme providing supplementary nutrition (300-400 calories and 15-20 g protein per day per child) to all children studying in both the schools. About 50% of the children studying in the school are from neighbouring villages.

Study Design

Qualitative Methods

The key issues considered for qualitative data collection were: (a) What the community thought were important morbidities in school age children, and (b) What they regarded as likely etiology of these conditions. The methods used were focus group discussions (FGD) and in-depth interviews (IDI).

1. Focus Group Discussion: Six FGD’s were held, each group having 6-8 participants (two groups of married women; one group of married men; a group of school teachers; a group of paramedical workers and a group of school age children between 11-15 years of age). FGDs were held with such diverse groups in order to get a wide cross sectional view of the community on the morbidity of school age children. The participants were known to one another since all of them belonged to the same village. This variation was hence unavoidable.

2. In-depth Interviews (IDI): These were held in order to get a deeper insight into the community’s perspective of morbidity in school age children. It was felt that it would be appropriate to interview men and women with children in school age for this issue. However, men were unwilling to take part in in-depth interviews although they participated in group discussions. They felt that the health care of children was a woman’s domain and that they would not be able to convey much information. Hence women who understood the purpose of the study and were willing to discuss freely with the investigators were interviewed. The interviews were stopped after 8 women since no new information was forthcoming.

Based on the analysis of qualitative data, a structured questionnaire was designed. Fifteen per cent of married couples with children from the village were randomly selected (which included 80 women and men each) and interviewed with the questionnaire for validating the qualitative data. The men and women were interviewed separately and in the absence of the spouse.

Other Epidemiological Methods

1. Cross Sectional Survey: A one time cross sectional morbidity survey of school age children in the village was carried out by a pediatrician in the government schools between November 1995-February 1996. A detailed clinical examination including measurement of height and weight and screening for refractive errors and hearing was carried out. Weight was measured to the nearest 0.5 kg after making the children stand erect on a weighing machine without their footwears. For measuring the height, one of the walls of the classroom was calibrated using a metallic tape. The children were made to stand against the wall after removing the footwear with their heels and buttocks touching the wall. They were made to look straight and the height measured to the nearest 0.5 cm. School teachers who were explained about the method of recording the same measured height and weight. In children between 5-12 years of age, weight (kg) ´ 100 / height (cm2) was the anthropometric index considered for assessing the nutritional status and a value of £0.13 was taken as an indicator of malnutrition since this was close to the suggested value applicable to children in Tamil Nadu(11). A diagnosis of worm infestation was made from a history of passing worms in the stool and that of anemia by the presence of pallor in the tongue, nail beds and conjunctiva. Vitamin A deficiency was diagnosed in the presence of both xerosis and Bitot’s spots as per the criteria laid down by WHO for field survey(12). Ear infection was diagnosed by the presence of ear discharge on examination. Visual acquity was assessed by using Snellen’s chart and hearing by Rinne’s test using a tuning fork with a frequency of 256. Owing to practical diffi-culties, audiometry could not be done in the field.

2. Longitudinal Survey: Using census data, 100 families that had children between 5 - 15 years of age were randomly selected and all children between 5-15 years of age in these families were included in the cohort. There were 156 children in the cohort out of which 6 children left the village within a period of 3 months after starting the study. They were excluded from the study and the remaining 150 children (68 girls and 82 boys) were followed up for a period of one year from June 1996 to May 1997 for morbidity and diet intake. The children were examined every fortnight by a trained nurse and details of illnesses suffered by them during the previous 2 weeks recorded on a predesigned proforma. She was periodically checked and supervised by a pediatrician. On alternate visits, dietary intake during the previous 24 hours was recorded by recall method. The quantity of cooked food ingested was indicated in commonly used household cups, approxi-mate weight estimated and the nutrient value calculated as per standard criteria(13,14). Each child had 12 dietary intake observations. The average nutrient intake was calculated for each child and subsequently for each age.

Data Analysis

Data were organized and analyzed using Wordperfect and Text base Alpha packages for analysis of qualitative data and Epi info 6 and Quattro pro, for quantitative data. The statistical tests used were Chi Square test for proportions and Student’s "t" test for paired and unpaired samples and Z test for large sample means.

Results

Morbidity: People generally felt that fever ("joram"), respiratory infections ("shali, irumal"), abdominal pain ("vayathuvali") and headache ("thalaivali") were common morbidity in school age children and that fever and respiratory infections were more frequent during rainy season. Other morbidity that they considered common in children were dental and skin problems. On probing further many people said that worm infestation, anemia and angular stomatitis were also present in school age children. The investigators therefore felt that the community in general did not consider worm infestation, anemia and angular stoma-titis as morbidity in school age children since these were not spontaneous responses of the participants and could be elicited only by probing questions. People generally felt that children in primary school fell ill more often than older children and that both girls and boys fell ill with similar frequency.

Etiology: As regards causes of morbidity, many of them said that they did not know what caused these morbidity. Some felt that change of water, exposure to cold, intake of food that did not agree with the body, excessive heat in the body, fear, eye problems and poor hygiene caused some of the morbidity in school age children. For instance, many believed that bathing in tap-water one day and in well water another day would cause respiratory infection while some felt that excessive heat in the body manifested as abdominal pain, headache, respiratory infection and also fever. Many people thought that rice eaters would get worms because of accumulation of rice in the stomach, just as maggots form in stale rice. Some of them remarked that previously children were given purgatives periodically and that kept their stomach clean and there were no worms. These days nobody gave pur-gatives and therefore rice kept accumulating in the stomach and gave rise to worms. The staple diet of these people is rice which is taken along with concoctions made of tamarind water known as "kozhumbu" and "rasam"

Structured Questionnaire

Morbidity: Of the 160 people interviewed with a structured questionnaire, fever was thought to be ailment by 95%, respiratory infection by 85%, headache by 80% and abdominal pain by 53%. Many of the respondents gave more than one response. On specific questioning 79.3%, 78.1% and 61.3% of the respondents respectively expressed that worm infestation, angular stomatitis and anemia also affect school age children.

Etiology: More than 40% of the respondents did not know what caused fever, headache, respiratory infection and worm infestation. Abdominal pain was considered to be a manifestation of excessive heat in the body by 66.9% of the respondents; worm infestation due to accumulation of rice in the stomach by 45.0%; headache due to eye problems by 26.3% and due to excessive heat in the body by 18.7%; respiratory infection due to change of water or getting wet by 45.6% and due to excessive heat in the body by 13.2%; fever due to getting wet by 28.2% and fear by 4.4% of the respondents.

Cross Sectional Survey

Anthropometry

The mean heights and weights of children were compared with the National Center for Health Statistics, USA(15) and affluent Indians(6) as shown in Fig.1. In both girls and boys these were found to be less than the reference standards. The difference appeared to increase with increasing age.

Morbidity

A total of 1,349 school age children were examined out of which 15 (2.5%) girls and 25 (3.3%) boys did not have any disorder. There was no gender difference among those with no disorders (p >0.05). The important morbidity observed is shown in Table 1, While anemia and worm infestation were significantly more common in girls (p <0.05); vitamin A and riboflavin deficiency, periodontal disease and injuries were more common in boys (p <0.05). There was no gender difference in the prevalence of other disorders. Among those with disorders, the average disorder per child was 2.5 for both girls and boys.

Longitudinal Survey

Nutritional Intake

The overall intake of calories, iron, ribo-flavin, niacin and vitamin A was significantly less (p <0.05) than the recommended dietary allowance (RDA) while that of protein and thiamin was not so. The staple food of the villagers is rice and the quantity consumed perhaps provided adequate protein and thiamin.

Morbidity: Incidence was calculated for acute illnesses suffered by the cohort as per examination and recall history during fortnightly visits. Fever, respiratory infections, abdominal pain and headache were observed to be common morbidity (Table II). The pattern of morbidity is similar to that obtained by qualitative methods. Since these data were obtained from children/parents, they reflect those that were considered to be morbidity by them. The average incidence of morbidity was 1,324 episodes/1,000 girls/year and 1,598 episodes/1,000 boys/year. There was no gender difference in the incidence of various morbidity (p >0.05). Out of 68 girls and 82 boys, 33 girls and 32 boys, respectively did not suffer from any morbidity during the follow up; there being no gender difference (p >0.05).

Fig. 1. Comparing the average heights and weights of the study group with affluent Indians and NCHS.

Table I - Morbidity in Cross-Sectional Survey of School Age Children (n = 1349)

* This was calculated only in children between 5-12 years of age (n=772)

** Children were diagnosed earlier and taking treatment from local hospital.

Table II – Mortality in a One-Year Longitudinal Study of School Age Children

Mean number of illness episodes/1,000 girls/year = 1324

Mean number of illness episodes/1,000 boys/year = 1598

Mean number of illness episodes/1,000 children/year = 1473

Comparing the mean number of episodes in girls and boys using Z test for large sample means:

Z = 1.95; p = 0.133

Discussion

Community’s Perception

In this study, it was observed that the community’s perception of important morbi-dity in school age children (headache, fever, etc.) were different from those observed to cause significant morbidity in them such as worm infestation, anemia and under nutrition (as revealed in the cross sectional study). They were also not aware of the etiology of many of these conditions. This discrepancy in the morbidity among school age children as perceived by the community (emic) and as seen by the physician (etic) brings out the gap that exists between the community and the health professionals. This gap has to be bridged by the health professionals who have to spend more time with the community educating them about important morbidity in school age children, their etiology and prevention. Unless people understand and realize that some of the morbidity such as anemia and worm infestation not considered as important by them can adversely affect their children, they are not likely to take appropriate remedial measures.

General Morbidity

The spectrum of morbidity seen in the cross sectional survey was similar to that reported in other studies in India(4-6,10). However, the prevalence of these disorders in these studies showed a wide variation ranging from, 2.3%-29.6% for worm infestation; 8.9%-27.1% for vitamin B deficiency; 6.3%-59.6% for vitamin A deficiency; 1.7%-15.8% for anemia and 10.9%-98.0% for malnutrition. This wide variation could be due to the actual difference in the prevalence of various disorders in different geographical location, population or different diagnostic criteria applied in these studies. There is, therefore, a need to have a uniform format in the country for assessing morbidity in school age children.

Nutrition

It was observed that despite implementa-tion of the mid-day meal scheme the intake of most of the essential nutrients by school age children was less than the RDA, perhaps due to the low socio-economic status of the population and consequent inability to afford adequate food. Dietary deficiency may be an important contributory factor to the suboptimal growth, anemia, vitamin A and riboflavin deficiency observed in this study. Studies have shown the average Indian diet to be deficient in iron and riboflavin(17,18). A deficient nutrient intake and substandard growth in children hailing from socio-economically backward families have been observed by other investigators(2,19-20). If optimal adult size is desired, adequate nutritional supple-mentation may have to be given even before children reach the adolescent stage(21). The energy supplementation given in the mid day meals might be enhanced. The prevalence of vitamin A deficiency(3.1%) observed in this study is a significant public health problem as per the criteria laid down by the WHO(12). Other investigators have also observed a high prevalence of vitamin A deficiency in school age children in India(22-24). Vitamin A prophylaxis program may thus have to be extended to school age children also.

In conclusion, this study has shown that what the community perceives as morbidity among school age children is different from the morbidity observed in them on clinical examination. The community is also not aware of the etiology of many of these morbidities. Therefore, educating the community about these conditions and their impact on the health of school age children, their etiology and prevention will go a long way in improving the quality of life of these children. Besides educating the community, other measures that may contribute to improving the health of school age children are increased energy, iron and vitamin A supplementation and periodic deworming.

Contributors: SA conducted this study as part of her project for award of Ph.D. degree by Pondicherry University. She will act as the guarantor for the study. SPP supervised her study and helped in the study design, analysis and preparation of the manuscript. PN helped in the study design and cross-sectional morbidity survey.

Funding: None.
Competing interests: None stated.

 

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