ISSN No. 2321-0206
UNIVERSITY
Public Health Research Series
Global Public Health Conference 2014 Proceedings
School of Public Health
Greetings from the Editorial Board of the Public Health Research Series! We invite contributions from researchers in the field of Public Health. Public health research in India is developing in a rapid pace. Several researchers are working in the field, putting in hours of sincere and concerted efforts. Much of this research remains unpublished. It is essential for the public health professionals to know about the various research activities going on in the country at any given point of time. The Public Health Research Series is a compilation of research work from various public health researchers. Soon we plan to become a peer reviewed indexed journal. The Series provides the platform for public health researchers to make their work known to the academic world. Young researchers, public health students, junior faculty of schools of public health, students of medical, allied medical and health sciences specialties, teaching faculty and senior researchers can all find a common ground in this publication. Manuscripts which are ready can be submitted to
[email protected] with the following check list of items: 1. Title page – title of the article, name of authors in order, institutional affiliation, address for communication, number of words of the article, 4-5 key words, short running title, acknowledgement, conflicts of interest 2. Main manuscript – written according to International Commission of Medical Journal Editors criteria as provided in www.icmje.org . The references should be written in Vancouver Style of referencing. Tables and Figures should be appropriately numbered and in the end of the manuscript. Figures and photographs have to be sent as JPEG attachments not exceeding 2 MB. 3. Copyright declaration – a detailed statement declaring that the research is the original work of the authors, the authors have all read the manuscript and agree with the findings, and they transfer the copyright of the article to the Public Health Research Series should be signed by each author. If you have formulated your ideas for research and need some help, we also offer technical guidance from our panel of expert faculty from the School of Public Health, SRM University. You can write to us with your research ideas and have a discussion with an interested faculty. This faculty can provide you technical assistance till the stage of publication of your manuscript. Please write to us at
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[email protected] for any further doubts or queries. We look forward to enriching this Public Health Research Series with more of your contributions and inputs. Editorial Team
School of Public Health SRM University SRM Nagar, Kattankulathur - 603 203 Tamil Nadu, India
Public Health Research Series
Global Public Health Conference 2014 Proceedings
School of Public Health SRM University
Advisors and Patrons Prof. P. Sathyanarayanan President, SRM University
ADVISORS AND PATRONS Prof. M. Ponnavaikko Vice Chancellor, SRM University
Prof. P. Sathyanarayanan
Prof. P. Thangaraju President, SRM University
Pro Vice Chancellor (Medical) SRM University
Prof. M. Ponnavaikko
Dr.Chancellor, NirmalaSRM Murthy Vice University Chairperson, FRHS, Prof. P. Bangalore Thangaraju
Pro Vice Chancellor (Medical), SRM University
Dr. Nirmala Murthy Chairperson, FRHS, Bangalore
Editorial Board EDITORIAL BOARD Editorial Director
Prof. Ch. Satish Kumar Dean, School of Public Health
Editor-In-Chief
Dr. Rajan R. Patil
Editor
Dr. Vijayaprasad Gopichandran Associate Editors
Dr. M. Bagavandas Dr. Anil Kumar Indra Krishna Ms. Geetha Veliah Dr. Kalpana Kosalram Editorial Assistant
Mr. P. Bala Ganesh
PREFACE
Global Public Health Conference 2014
The School of Public Health, SRM University organized the Global Public Health Conference 2014 on 21st to 23rd Feb 2014 at the SRM University, Kattankulathur campus. The main objective of the conference ws to bring together multiple specialists from various disciplines such as medicine, nursing, dentistry, public health engineering, environmental sciences and hospitality industry and engage in deliberations to move the agenda of public health forward. About the School of Public Health The School of Public Health, SRM University was established in 2007 with the key objectives of research, training and knowledge sharing in the realm of public health in India. There are 4 courses run by the school – Masters in Public Health, Masters in Biostatistics and Epidemiology, Masters in Clinical Trials, MBA-MPH dual degree program and Associate Fellowship in Industrial Health. A total of 182 MPH, 19 MSc Biostatistics and Epidemiology, 9 MS clinical trials, 12 MBA-MPH and 55 AFIH students have graduated from the school over the past 7 years. The Key research areas of interest of the School are,Maternal and Child Health, Quality of Life, Tribal Health, Social Determinants of Health and Behavior Change Communication. One of the activities of the school is organization of thematic conferences. In keeping with this objective the following conferences have been organized by the school in the past year: • Second National Conference of the Health Economics Association of India • Indian Association of Social Sciences and Health Conference About the Conference The Global Public Health Conference marks the coming together of all disciplines in public health. The various departments such as nursing, dentistry, community medicine, management, environmental engineering etc. are doing very high quality work in public health. There is a need to bring them together and share their knowledge and experiences. A grassroots worker in the field of community health nursing should be able to share her experiences with an IT professional working in the field of information technology in public health.There is also a lack of a professional body where all these specialties can converge. This conference has two unique characteristics: 1. It was designed in consultation with all the deans of the various schools and colleges in SRM. 2. It attempted to mainstream and showcase the role models of Public health in India. The organizing committee identified great contributors in the field of public health and werehonored during the conference.
The objectives of the conference 1. Bringing all disciplines together 2. Sharing of experiences of various disciplines 3. Learning from various disciplines 4. Starting a multidisciplinary professional body There were several International participants in the conference five from Canada, three from Nigeria, nine from Bangladesh, two from Srilanka, one participant from the USA and one each from Thailand, Indonesia and Libya. The conference was planned for a total of three days. There were three plenary sessions a. Multidisciplinary Approaches to Public Health b. Technology in Public health c. Pharmacovigilance Three panel discussions a. Leadership and Public Health b. Non-Governmental Organizations and Public Health c. Corporate Social Responsibility and Public Health
There were a total of 23 satellite sessions spread out over the first two days of the conference on various sub-themes. About the Conference Proceedings Book This book is a compilation of some of the oral papers and posters that were presented in the conference. The presenters converted their papers into full fledged manuscripts and sent it for review. These papers were peer reviewed by an in-house panel of reviewers at the School of Public Health. After feedback and modification, 37 of these papers have been processed for publication in this book. This book is being published as part of the Public Health Research Series – GPHCON 2014 special edition. We wish the readers the very best experience in reading and using the book for their own research ideas and activities.
CONTENTS Effectiveness of Various Issues of Family Life Education on Reproductive Health Among School Adolescents M. Abbas Study of Concentration of Particulate Matter from Traffic Emissions in Air along National Highway No-8(Kishangarh toll to Bagru toll) And Its Health Implications Subroto Dutta, Abha Sisodia
10
24
Knowledge and Practices of Menstrual Hygiene among Adolescent girls in Kathmandu, Valley Ashok Pandey, Umashankar, S.Meera Tandan, Deependra Panta, Madhu Pandey
33
Child Health as Human Right: An International and National Perspective Deepikaa Gupta, Swarnjit Kaur
40
National Rural Health Mission: How far AYUSH is mainstreamed in Odisha? Ranjit Kumar Dehury, Ranjan Pattnaik
47
Design and Development of Miniaturized Spirometer Using Android Enabled Device Karthikeyan.A, Khaleelu Rahman, Velmurugan.A
57
Process Documentation of Activities at an Urban Health Training Centre Dhikale PT, Dongre AR
63
Riots and Women's health: A Policy Perspective Sunita Basnet, Yerramalla Manasa Shanta
69
Burden of Non-Communicable Diseases among Adults in India: Evidence from Longitudinal Aging Study in India (LASI) Ramu Rawat
77
Rural Parent’s Perception on Uncompleted Basic Immunization Eliyana , Panarut Wisawatapnimit, RN, Ph.D. Pornruedee Nitirat, RN, Ph.D
91
A Systematic Literature Review for Statistical Evaluation of Asbestos Exposure Level M.Rajesh Kumar, R.Suresh, K.N.Karthick, H.Abdul Zubar
102
A study on the knowledge, awareness and practice of food labels among women consumers Shiny Lizia M, Preetha R
113
Impact of audio-visual communication in bringing health awareness among urban slum dwellers: Case study of Bangalore Urban District Vahini Aravind, Varghese Pulickal
124
Gender Preference for Children: Perspectives of Parents Rupsa Banerjee, Bratati Banerjee
135
A Study to Assess The Prevalence of Hypertension and Diabetes Mellitus Among the Adults in Rural Community, Kancheepuram District, Tamilnadu Hema Malini M
143
Use Open Source Software for effective monitoring and Capacity building in a Public Health Project Kabilan Annadurai
150
Factors influencing uptake of Postnatal care service in rural areas of Dadeldhura District of Nepal Kalpana Jnawali
154
Risk factors of Dementia among elderly residing in Varanasi City Kumar Avadhesh, Srivastava Manushi, Saroj K. Rakesh
165
The Relationships Between Selected Factors and The Occurrence of Malnutrition in Children Under Five Years of Age in West Nusa Tenggara Province of Indonesia Raden Ahmad Dedy Mardani, Kanokwan Wetasin, Wiparat Suwanwaiphatthana
171
The Role of Governance in Reducing Inequality in Health Care in Bangladesh Mohammad Shafiqul Islam
183
A Descriptive Cross-Sectional Study on Knowledge, Attitude and Practices Regarding Needle Stick Injuries Among Staff Nurses of KLES Dr. Prabhakar Kore Charitable Hospital, Belgaum Timalsina Narendra, Anil P Hogade
198
Cause And Effect Analysis In A Blade Manufacturing Unit Using FMEA C. Karthik, K.S. Prabhakaran, M.Karthikeyan
211
Ethics in Public Health Care Laxmi Thakur, Arvind Singhal
219
Defining Calorie Intake as a Measure of Under-nutrition and Deprivation in Rural India Abha Gupta
231
A study of quality of life of elderly people in the Tangra area of Kolkata Jitendra Kumar Singh, Sandip Kumar Ray, Amal Kumar Basu
240
Pattern of Institutional Delivery in Dadeldhura District of Nepal: A Cross-Sectional Study Damaru Prasad Paneru
247
Inter-District Comparison of Total Fertility Rate in Bihar: Improving Programme Implementation for Better Outcomes Ritu Agrawal, Bhaskar Mishra, Amit Mohan Prasad
256
The Public Health significance and issues related to Noise-Induced Hearing Loss: The Indian Scenario Sharanya Narasimhan, Chandru Jayasankaran, Ramakrishnan Rajagopalan C.R.Srikumari Srisailapathy
264
The Contours of public ‘Wellness’: In the Context of Tourism S. Rajamohan
278
Impact of internet addiction on Physical Health, Mental Health & Social Well Being of college students in Bengaluru, the Silicon Valley of India Sharmitha K, Satish Kumar
283
The Fallacies of Food Service in the Out-Door settings: An arduous practice in the premise of Public Health Thirulogachander, R. Parimala, J. Eugene
292
Health Status of Workers of Textile and Dyeing Industries of Pali Industrial Area, (Raj) India Subroto Dutta, Shubhra Singh
296
KAP study of substance use in hostellers and day scholars Arthi R
302
Trust Worthiness - Provider’s perception of Trust in Healthcare Sunil Mathew, Vijayaprasad Gopichandran, Kalpana Kosalram
316
Use of Folk Media (Drama) In Communication of Public Health Messages on The Occasion of World No Tobacco Day Uddalak Chakraborty, Kaushik Majumder, Sayantan Chakraborty, Kinjal Kumar Nanda, Anwita Basu, Sandip Kumar Ray
324
Access to inheritance and property rights and well-being of elderly women in rural Uttar Pradesh Niharika Tripathi
329
GLOBAL PUBLIC HEALTH CONFERENCE 2014 Public Health—A Multi- Disciplinary Approach Key Note Address delivered by Dr. Satish Kumar, MD, MNAMS, FIPHA (Chief UNICEF office for Tamil Nadu and Kerala, Chennai) February 21, 2014; School of Public Health, SRM University, Tamil Nadu
The subject of this Global Public health Conference is most appropriate and I congratulate Prof (Dr) Satish, the Dean, School of Public Health of this University and his team for organising this conference. We in UNICEF are extremely happy to be a part of this conference and are also delighted to note that the workshop is being held at the most appropriate period of time in the history of Public Health in India. Our country is likely to be certified in a few months from now in 2014 as a Polio free country. The year 2014 also marks the 25 th anniversary of the Convention on the Rights the child-adopted by the UN General Assembly in 1989. By ratifying this convention in 1992, India broke the ground rules for children by moving their survival, development, protection and participatory rights from the domain pf welfare agenda to the binding legal commitments. Now, the country cannot cite paucity of funds as an excuse for not reaching out to children- even those most marginalised or difficult to reach- with essential health, nutrition and education services. The year 2014 also happens to be the penultimate year for organising our capacities and resources to achieve Millennium Development Goals (MDG.s) by 2015. Review of progress towards achieving MDGs makes it clear that for the first time in history we have the possibility of eradicating global poverty during our life time. MDGs related to Education are likely to be realised in our country and a few Indian states have already achieved goals related to child health, maternal health and drinking water coverage. However, many Empowered Action Group states like U.P. Bihar, Chattisgarh, M.P. Rajasthan and Assam are likely to leave behind and may not reach many MDGs. Health and development status of children and mothers in these states leave much to be desired and their critical survival and development needs remain largely unmet. Infant Mortality Rate in our country today ranges from 12 in Kerala to 59 in M.P. A girl born in Kerala is likely to live at least 20 years longer than the one born in U.P, Rajasthan or M.P. There are thus, glaring disparities in health and development status of population in different regions of our country which unfortunately continue to persist. These survival and development disparities between different states and also within different districts of the same state pose daunting challenge to the discipline of Public Health and its practitioners. We can successfully face this challenge if we have the courage of conviction and follow the principles and practice of Public Health with sincerity, tenacity and ingenuity. The strategic strength is provided by the multi-disciplinary approach based on principles of Public Health and Epidemiology to solve the problems of disease burden and development disparities In the present era of 21 st century, Public Health faces challenges that are complex with many social, economic and political variables belonging to different settings from country to country, state to state to state and district to district. The health and development scenario is further complicated by changing demography, disease epidemiology, climatic change
and unregulated private sector in provision of health care. Public health professionals need not only multi-disciplinary knowledge and skills to deal with the situation but also imbibe leadership skills to inspire fellow colleagues to join the struggle against existing disparities, health inequities and emerging environment and governance challenges The first generation diseases like Tuberculosis, Malaria, Diarrhoeas and Vaccine Preventable Diseases have re-emerged and second generation problems like degenerative and geriatric disorders, cancers, cardiac diseases have emerged in a big way. Besides, natural disasters, bio –terrorisms, displaced populations and complex emergencies are also going to be critical determinants of success or failures of large scale Public Health programmes that countries and their governments design and implement in years to come. Let us also remember that Public Health decisions are largely political decisions and Public Health practices and policies require political blessings Availability of resources is not enough. Whether or not the available resources are allocated to Public Health is a political decision. The fact for example that China devotes 2.7% of its GDP to government expenditure on health care compared with India’s miserable 1.2% has been the outcome of political and public policy decisions of the governments in two countries. This is directly relevant to the much greater health achievements and positive health transition in China. Political advocacy, therefore is one of the most desirable skills required of Public Health leaders of a country. Public Health systems and practices will be greatly influenced in future by the advances in basic sciences and technologies specially bio technology, information technology and telecommunication. Genome projects and regulation imposed by GATT (General Agreement on Trade and Tariff) and TRIPS (Trade Related Aspects of Intellectual Property Rights) will affect pharma industries. From ‘process –patent’ production, pharmaceutical industries will be governed by ‘product patent’ production and many companies involved in generic sale of drugs to domestic market may not survive. The cost of drug may increase with serious implications for Public Health system in any country. Advances in Communication and Information Technology will go a long way in capacity building of health professionals, health system strengthening and improved transport and referral compliance. This will certainly help extend the outreach of essential Public Health care to the most marginalised and difficult to reach population groups. It is important to point out that advances in science, technology and multi-disciplinary skills will only help Public Health achieve its objective if there is a strong political will and social awareness to transform available knowledge and technology into wisdom to enable us use our resources to bridge development disparities and health inequities in different countries and in different regions within the same country. Thank you
10
Effectiveness of Various Issues of Family Life Education on Reproductive Health Among School Adolescents M. Abbas
Abstract Development of Family Life Education (FLE) on Reproductive Health (RH) is a critical aspect of reproductive education among adolescents. This paper reports on a project that aims at identifying adolescent’s knowledge and attitude on RH components focused learning activities and generate adolescent’s recommendation for the development of effective FLE on RH state. Objective: To compare the rural and urban adolescent students on experimental responses on pre and post test regarding the knowledge and attitude on various issues of FLE on Reproductive Health. Method:The research project utilized unique experimental method, which drew on the knowledge and attitude of adolescent students on RH to explore the views of their adolescent using developed the questionnaire on knowledge and attitude. The researcher interviewed 364 adolescents to clarify their perceptions of current cognitive and affective domain of FLE on RH and to explore the ideas for strengthening the cognitive and affective domain on RH. The researcher adopted instructional strategies on developing the RH awareness, values and attitudes towards FLE on RH; and ability to practice the RH rights in future life situations among the adolescents of higher secondary school students of selected eight schools of Dindigul district, Tami Nadu. Result: The RH components that emerged focused on the need to clarify the relevance of adolescent RH knowledge and attitudinal practice reward individual contribution to the community that facilitates feedback and reflection on RH knowledge and attitude. There was significant difference in knowledge and attitude scores of the adolescents from rural and urban areas in pre test and post test of various issues of RH (p65 years of age)
9.6
4.
Children(< 14 years of age)
20.0
5.
Athletic activities
7.0
Total
52.5
PM Exposure and Common Respiratory and Cardiovascular Diseases The common respiratory and cardiovascular diseases associated with PM exposure are discussed in brief as follows: • • • • • • • •
Acute Respiratory Distress Syndrome(ARDS) Chronic Obstructive Pulmonary Disease(COPD) Broncho-Pulmonary Dysplasia(BPD) Chronic Bronchitis Asthma CorPulmonale Dyspnea Emphysema
31
Conclusion Airborne PM is reportedly known to cause wide-ranging health effects. PM (liquid or solid particles) dispersed in air is generally classified as ultra-fine (size range less than 0.1 µm), fine (0.7–1 µm) and coarse (1–200 µm). Apart from the natural sources such as forest fire, volcanic eruptions and wind-blown anthropogenic emissions from industries, vehicles, incomplete combustion of fossil fuel, careless waste treatment and disposal, commercial and residential combustion plants, and industrial combustion plants contribute to elevated levels of atmospheric PM. The results from the study suggest that PM concentrations are increasing along the highways at an alarming rate which is seen as one of the biggest threats for air quality management. The pollution levels along the study area as a result of vehicular emissions have risen to a threatening level at the moment. Therefore we need to tackle the problems before they reach a critical level so as to prevent the wellbeing of the living organism and the environment as a whole. The study strongly indicate that long-term exposure to even low levels of PM are linked with deleterious health problems, including asthma, bronchitis, chronic obstructive pulmonary disease, pneumonia, upper respiratory tract and lower respiratory tract disorders. Findings suggest that fine PM is a risk factor for premature mortality, cardiopulmonary and lung cancer mortality. Air quality along the Highway is deteriorating at a fast pace owing to the fastgrowing vehicular fleet. Alarming levels of PM are reported along the study area. Despite such high levels, lack of studies
especially in the field of environmental epidemiology, is discouraging. Immediate measures are essential to streamline recording the morbidity in a more detailed fashion. Data should be made easily available to the research community by publishing on the web or making available statistical documents in public domain. Such a reform would give great impetus to studies on air pollution and health. Ambient air quality standards for particulate matter (PM10 and PM2.5) might be newly promulgated after serious consideration of existing data on public and environmental health in India and elsewhere. Refrences 1. Reducing risks, promoting health. Report, World Health Organization, Geneva, 2002. 2. Janssen N. Personal exposure to airborne particles. Ph D thesis, Kuopio, Finland 1998. 3. Dockery D , Pope C A, Xu X , Spengler J, Ware J, Fay M, Ferris B and Speizer F. An association between air pollution and mortality in six U.S. cities. New England Journal of Medicine 1993; 329:1753-1759. 4. Brunekreef B, Holgate S.T.Air pollution and health source . The Lancet 2002; 360 : 1233 - 1242 5. Gauderman W J, Avol E, Gilliland F, Vora H, Thomas D, BerhaneK.The effect of air pollution on lung development from 10 to 18 years of age. New England Journal of Medicine 2004; 351(11):1057–1067. 6. FengerJ.Urban air quality.Atmospheric Environment 1999; 33: 4877– 900.
GLOBAL PUBLIC HEALTH CONFERENCE 2014
7. National ambient air quality objectives for particulate matter executive summary, Part 1: Science assessment document under Canadian Environmental Protection Act (CEPA). Minister, Public Works and Government Services Canada 1998; 1–25. 8. Rombout P.J.A .Health risks in relation to air quality especially particulate matter Interim Report. National Institute of Public Health and the Environment Bilthoven 2000; 1–63. 9. Bahadori T, Helen S, Koutrakis P. Issues in human particulate exposure assessment: relationship between outdoor, indoor and personal exposure. Human and Ecological Risk Assessment 1999;5: 459– 70. 10. Gamble J F. PM 2.5 mortality and long-term prospective cohort studies: Cause-effect or statistical associations. Environmental Health Perspectives 1998;106: 535–49. 11. Hext P M , Rogers K O, Paddle G M. The health effects of PM2.5 (including ultra fine particles). Reviewed for CONCAWE by Evans M etal.CONCAWE, Brussels1999.
14. Kleeman M J, Schauer J J, Cass G R. Size and composition and distribution of fine particulate matter emitted from wood burning, meat charbroiling and cigarettes. Environmental Science and Technology 1999; 33: 3516–23. 15. Shi J P, Khan A A , Harrison R M. Measurements of ultra-fine particle concentration and size distribution in the atmosphere. Science of the Total Environment 1999; 235: 51–64. 16. Wrobel
A,
Rokita
E,
Maenhaunt.
Transport of traffic related aerosols in urban areas. Science of the Total Environment 2000; 257: 199– 211. 17. Simoneit B R T, Elias V O. Organic tracers from biomass burning in atmospheric particulate matter over the ocean. Marine Chemistry 2000; 69: 301–12. 18. Miranda J, Crespo I, Morales M A. Absolute principal component analysis of atmospheric aerosols in Mexico City. Environmental Science and Pollution Research 2000; 7:14–18. 19. Harrison R M, Deacon A R, Jones M
12. WHO, Particulate matter. In Air Quality Guidelines – Second Edition, WHO Regional Office for Europe, Copenhagen, Denmark 2000.
R ,Appleby R Sources and processes
13. Lippmann M. Human health risks of airborne particles: Historical perspective. In Air Pollution in the 21st Century: Priority Issues and Policy (ed. Schneider, T.). Elsevier Publications 1998; 49–85.
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affecting concentrations of PM10 and PM2.5 particulate matter in Birmingham (UK). Atmospheric Environment1997; 20. Miguel
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GLOBAL PUBLIC HEALTH CONFERENCE 2014
Knowledge and Practices of Menstrual Hygiene among Adolescent girls in Kathmandu, Valley Ashok Pandey, Umashankar, S. Meera Tandan Deependra Panta, Madhu Pandey
Abstract Menstruation period is a risk factor for various infections. Adolescents’ school girls are more vulnerable to infection. The study was carried out to assess the knowledge and practices about menstruation among adolescent girls in Kathmandu Valley.Methods: A descriptive, cross-sectional study was carried out to explore the knowledge and behavior of the menstruation in adolescent girls. One hundred adolescent girls of age 12-18 years from one public school and another private school of Samakhusi, Kathmandu. Results: From the study, with the mean age of 14 years, 7% were married in Public School. The average age of the first menstruation was 12.37 years. About 84% had accurate knowledge about menstruation is the physiological process.And only 42% had accurate knowledge on theCauses of Menstruation. Only 30% had sleep separate place during period. Seventeen percent had used old clothes in menstrual period.About 6% had shared the pad with sister and mother. About 71% feel upset and tension during the first time of menstruation (Menarche). Conclusions: Although knowledge was better than practice, both were not satisfactory. So, the girls should be educated about the process and significance of menstruation, use of proper pads or absorbents and its proper disposal. This can be achieved by giving them proper training and health education (by teachers, family members, health educators, and media) so that there won't be any misconception to the adolescent girls regarding menstrual hygiene. Key words: Knowledge about menstrual hygiene, Practice, Hygiene,Peri-pad, Reproductive age, Genitalia Menstruation.
Introduction Menstruation is part of the female reproductive cycle that starts when girls become sexually mature at the time of puberty. It is a phenomenon unique to the females. During a menstrual period, a woman bleeds from her uterus via the vagina. The menstrual rhythm depends
on the hypothalamus- pituitary- ovarian function whereas the amount of blood loss depends upon the uterine contraction. The menstrual period lasts from three to seven days. Each period commences approximately every 28 days if the woman does not become pregnant during a given cycle. A deviation of two or three days from the twenty eight day rhythm is quite common.[1]
Padmashree School of Public Health, nearNagarbhavi circle, Nagrabhavi, Bangalore, 560072, India
GLOBAL PUBLIC HEALTH CONFERENCE 2014
The menarche or time of onset of menstruation varies with race and family, but the average for most girls is from 10 to 14 years until 45 to 55 years. Geographical conditions, racial factors, nutritional standards, environmental influences and indulgence in strenuous physical activity can all affects the age of menarche. A woman will have approximately 500 periods in her lifetime. The estimated blood loss is between 50 ml and 200 ml.[2] During menstruation were considered holy they were not allowed to touch any male, fetch water, enter the kitchen and worship the gods.[3] Adolescent girls often visit the outpatient endocrinological clinic because of menstrual disorders Bhattacharya, S..[4] During menstruation women use homemade sanitary napkins in the villages, they are not cleaned properly. Menstruation period is a risk factor for various infections.[5] the types and frequency of problems related to menstruation among adolescent girls and the effect of these problems on daily lives might be different in Nepal and implication may vary. In the current situation, where there is an absence of menstrual hygiene and management issues in the policy debate, and hence in investments and actions is needed. A female’s urethra is quite short and prone to ascending infections. Adolescent girls might suffer from many problems without even being fully aware of the cause.The girls should be educated about the significance of menstruation and development of secondary sexual characteristics, selection of a sanitary menstrual absorbent and its proper disposal. There is a need for compulsory sex education and health education on menstrual hygiene so that they can discuss freely about it without hesitation. Hence, this study was done to evaluate the knowledge and practice of menstrual hygiene in rural adolescent girls of Nepal.
Methods A descriptive, cross-sectional study was carried out to explore the knowledge and behavior of the menstruation in adolescent girls.One hundred adolescent girls of age 1218 years from one public school and another private school of Samakhusi, Kathmandu Valley were involved in this study. Altogether 37 questions were asked to each of them.Ethical approval was taken from Little Buddha College of Health Sciences and concerned schooland Verbal informed consent was taken from each respondent. They were assured for the anonymity and confidentiality of the information and allowed to refuse to participate in the study at any time if they wish.The sample size of the study was 100 adolescent girls. The research was done by Purposive NonProbabilitymethod of sampling technique. The duration of the study was three months. The methods applied for the data collection tool was Self-administeredstructured closed ended questionnaire.The validity of the instrument was maintained by consulting with the advisor and Colleagues. A questionnaire was modified according to their suggestions. Reliability of the instrument was maintained by pre-testing the similar settings. Pre-testing was conducted at New Himalayan School; Kathmandu in 10% of total sample. Data analysis was done by simple manual analysis using chi-square test, frequency and percentage by SPSS and Excel. Results All the girls were between 11 to 18 years age group while they studied from class-8 to class- 10 (Table1) Around 52.0% of girls mentioned that menstruation begins at the age of 12 years. Among them 67% was belong to the Hindu religion and 50% of the respondents was in the Janajati (Scheduled caste) Ethnicity.
35
Table 1: Distribution of Adolescent girls according to Socio-demographic characteristics Characteristics
Frequency (n=100)
Percentage (%)
12-13 Years
21
21
14-15Years
59
59
20
20
class 8
40
40
class 9
39
39
class 10
21
21
Married
7
7
Unmarried
93
93
Hindu
67
67
Buddhist
20
20
Christian
11
11
Muslim
2
2
Brahmin
26
26
Chhetri
17
17
Janajati
50
50
7
7
Age
>16Years Educational status
Marital status
Religion
Ethnicity
Dalit
The average age of the first menstruation (Menarche) was beginning at the age of 12.37 years. On asking the question about the menstruation, 84% of the girls told that menstruation is the Physiological process. On asking to the cause of menstruation only 42.0% replied that it is due to hormones. It was found that more than half fifty five percent of the Adolescent girls told that ageing is the cause of Menstruation. Their knowledge seems to be inefficient because only 23% know that bleeding is from uterus. On asking the question about the how often the pad use during the period that 52% of adolescent girls were changed the
pad daily, followed by 33% were changed the pad depending on situation (when the blood is flow more than the normal). During the period 83% of the adolescent school girls were used special pad. Out of 100 adolescent school girls asking the question about the Practice during period, regarding Pad share, Reuse and Dispose on menstruation, only 6.0% shared the pad during the menstrual period. On the pad share purpose 88.0% were re used. Among the respondents Maximum percent 50.0% were disposed the pad in the dustbin for disposal purpose.There
GLOBAL PUBLIC HEALTH CONFERENCE 2014
are only 93.0% of girls who clean their genitalia for menstrual purpose while only 70% use soap while cleaning. On the question of technique used, 53% of the adolescent girls washed through anterior to posterior technique. Most of the girls expressed that 71% feel upset and tension during the first time of menstruation. First menstruation is often traumatic and very negative experience.
Among the all adolescent girls, 43.0% of girls were taught about menstruation by their guardian's and friends. Teachers still 88.0% of girls have a view that these things like cause, practice of mensuration are not taught them properly. Results show that these Nepalese girls 41% of girls don’t cook food during the menstrual period. And 72% of the adolescent girls told that they sleep same place (as usual place) during period.
Table 2: Distribution of adolescent girls about Sleep in house during menarche, and practice during menstruation
Characteristics Use pad Yes No How often 1 in 1 period Change daily Depending on situation Material use Old clothes Special pads
Frequency(n=100)
Percentage (%)
99 1
99 1
15 52 33
15 52 33
17 83
17 83
Table 3: Distribution of adolescent girls Practice during period, regarding Pad share, Reuse and Dispose on menstruation
Characteristics Share Yes No Reuse Yes No Dispose Mud Dustbin Separate place
Frequency(n=100)
Percentage (%)
6 94
6 94
12 88
12 88
7 50 43
7 50 43
37
Table 4: Distribution of adolescent school girl’s practices on clean genetalia for menstrual purpose, technique used for cleaning, and use while cleaning the genitalia Characteristics Clean genetalia Yes No Technique used Anterior to posterior posterior to Anterior Randomly Use while cleaning Soap and Water Plain
Frequency (n=100)
Percentage (%)
93 7
93 7
53 18 29
53 18 29
70 30
70 30
Table 5: Education of respondents by sleeping place during menstruation period Education
Sleep during menstruation period separate place
separate place
Total
N
%
N
%
N
%
class 8
18
45
22
55
40
100
class 9
10
25.64
29
74.36
39
100
class 10
2
19
19
81
21
100
χ²=9.510 pValue=0.009
Source: Field survey, 2011 N: Number of cases; %: Percentage, χ²=Likelihood value It is evident from the present study that the Chi- Square value computed for the education of respondents, with Sleep during menstruation period of respondents is statistically significant (p 36 Gender Male Female
Frequency
Percent (%)
136 45
75.1 24.9
87 94
48.1 51.9
64 117
35.4 64.6
66 115
36.5 63.5
133 48
73.5 26.5
99 82
54.7 45.3
Breastfeeding Time (months) Non-exclusive (< 6) Exclusive (≥ 6) Child’s Birth weight (grams) Low birth weight (< 2500) Normal birth weight (≥ 2500) Mother’s factors Education Elementary school High school Mother’s Occupation Not working Working
Mother’s Knowledge of children malnutrition Inadequate knowledge Adequate knowledge
82 99
45.3 54.7
173 8
95.6 4.4
62 119
34.3 65.7
Household factors Parenting Mother Grandmother Family types Extended family Two parents
175
Table 2: Prevalence of children malnutrition
Prevalence of children malnutrition
Frequency
Percent (%)
78 103
43.1 56.9
59 122
32.6 67.4
66 115
36.5 63.5
Stunting Yes No Wasting Yes No Underweight Yes No Results and Analysis The majority of children were less than 36 months (75.10%). The majority of children gender was female (51.90%). The majority of children had been breastfeed time of exclusively (64.60%). The majority of children had normal birth weight (63.50%). The majority of mother’s education was elementary school (73.50%). For the mother’s occupation, the majority were not working (54.70%). Mother’s knowledge related to children malnutrition, the majority of mother had been adequate knowledge (54.70 %). Regarding household factors, the majority of parenting was mother (95.60%). Concerning to family types, the majority were two parents (65.70%). The prevalence of children malnutrition in this study was found to be stunting (43.10%), followed by underweight (36.50%), and wasting (32.60%). Stunting There was statistically significantly relationship between child’s birth weight and stunting (p-value 2 years spacing between last two pregnancies. Birth spacing reported in our study is lesser than that was reported in Kirtipur Municipality of Kathmandu among the ever married women of reproductive age.[11] This variation might be due to the differentiation in the profile of participants and residential place with variability in access of delivery services. Four out of every five had ever had institutional delivery at least once, while almost one-fifth had ever delivered at home. It reflects that there has been changing trends with increased adaptation of institutional delivery. Hence, the findings corroborates with the observations of Shrestha et al.,[10] About 95% mothers had at least one time ANC visit during index pregnancy wherein almost two-third mothers had done four ANC visits. Proportion of first ANC visitors reported in our study were higher than that was reported in several studies conducted in Nepal [12-15] and the proportion of first ANC coverage was almost close to the DoHS report 2010/11.[13] WHO reported that 58% expectant mothers had first ANC visits and 50% had four ANC visits in Nepal in 2012 and these are lesser than the regional average of SEAR.[16] Findings of this study with respect to first ANC coverage are close to the American/Sri Lankan achievements
(95%), and fourth ANC visits are more than regional averages of SEAR (52.0%).[16] Variations in the ANC coverage might be due to the area specific findings. Although three quarter of the participants had their first ANC visit during the first trimester of pregnancy, it was lower than the standards laid down by WHO for early registration of pregnancy. More than four-fifth received ANC services from primary level health care facilities. Similar observations were made by Gyawali et al., in Midwest region of Nepal.[12] Majority of the participants had their first pregnancy during 20–24 years, while 28.3% had first conception during adolescent (Mean age at first pregnancy: 20.48 years) period which was slightly higher than that was reported in Kavepalanchok district (20.01 ± 3.07 years) in 2011.[10] Out of 516 participants, 77.3% had institutional delivery for the index pregnancy. Our findings are higher than that was reported by Kesterton et al.,[17] and Varma et al.,[18] for India, several studies conducted in Nepal; and a study from Nigeria.[10-15,19] Furthermore, institutional deliveries reported in this study were lesser than that was observed in Dhanusa and Kathmandu districts of Nepal, where almost 90% had institutional deliveries.[13] Majority (59.6%) of the participants delivered at primary health care facilities and 40.4% delivered at hospital. Hospital deliveries were reported from 31.0% to 88.0% among all institutional deliveries in Nepal.[8,14,20] Majority of the participants in our study delivered at primary health care institutions; however, hospitals were found to be more utilized in others studies from conducted in Nepal. [12,14,20] The differences in findings might
253
be due to the limited access to hospital services and improved delivery care facilities at primary health care institutions. Further, Government of Nepal has adopted to develop some of the primary level health care facilities into birthing centers which synergized the service delivery. About twothird went on foot for delivery at health facility where one-third had accessed delivery services by ambulance/vehicle. About two-third participants had no travel expenses because they had accessed care on foot. These findings are in agreement with one of the national level Indian study.[17] District Health Office statistics of Dadeldhura revealed that 63.0% of expected pregnancies had delivered with the assistance of health workers in 2011/12. A large variation was reported from 8.0% to 55.0% within the study clusters in the same year. Department of Health Services (DoHS), Nepal also reports the wide ecological and regional variation in the deliveries conducted by health workers in Nepal with 93.0% in Dhanusa (plain) Nepal and 7.0% in Manag (mountain) districts of Nepal.[13] Within the country, the least proportion of deliveries were assisted by health workers was observed in western and the highest in central region. Similarly, World health statistics reveals that the highest proportions of birth attended by SBA were there in Europe (98.0%), while only 59% in SEAR. Wide variation has been seen in SEAR i.e. 99% births are attended by Skilled Birth Attendants in Sri Lanka whereas only 36% in Nepal and 47% in India. These differences indicate that Nepal has a long way to achieve the target of 60% births attended by SBA to achieve Millennium Development Goals. Almost 55.0% participants were known about at least one danger sign/complications
occurring during delivery. Almost all (96.5%) opined that institutional delivery is safe. Almost three quarters were known about the SDIP and 95% of institutionally delivered mothers got incentives under SDIP. Bhusal et al.,[21] reported that 100% women delivering at health facility were known about the SDIP and 95% got incentives, while DoHS reports the lower performance in incentive received status with 89.0% coverage.[13] Conclusion Quite excellent (95.0%) antenatal registration practice was observed among the participants; however, only two third had four ANC visits. About 77.3% had institutional delivery. Majority (59.6%) had delivered at primary health care facilities. Three quarters were known about SDIP and 95.7% got incentives. Establishment of pregnancy monitoring and counseling system to improve their compliance and strengthening the primary level health care facilities will further increase institutional delivery practice. Acknowledgment The author is thankful to the University Grants Commission, Nepal for the financial support, District Health Office, Dadeldhura for the permission to conduct this study in its jurisdiction. References 1. World Health Organization [WHO]. World Health Statistics 2011. Printed in France. WHO Library Cataloguingin-Publication, Geneva 2011. 2. Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health 2011; 10:31.
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3. WHO, ICM, FIGO. Making pregnancy safer: The critical role of the skilled attendant. Department of Reproductive Health and Reseach. World Health Organization, Geneva. 2004. 4. MoHP/New ERA/ ICF Macro International. Nepal Demographic and Health Survey: Preliminary report. Population division, Ministry of health and Population, Nepal 2011. 5. Family Health Division, Department of Health services. Nepal. Nepal Maternal Mortality and Morbidity Study 2008/9. Family Health Division, Department of Health services, Ministry of Health and Population, Nepal 2009. 6. National Planning Commission, Government of Nepal and United Nations. Nepal Millennium Development Goals Progress Report. Government of Nepal National Planning Commission Singh a Durbar Kathmandu, Nepal 2010. 7. Mesfin N, Damen HM, Getnet M. Assessment of safe delivery service utilization among women of child bearing age in north Gondar Zone, North West Ethiopia. Ethiop J Health Dev 2004; 18:31-7. 8. Dhakal S, van Teijlingen E, Raja EA, Dhakal KB. Skilled care at birth among rural women in Nepal: Practice and challenges. J Health Popul Nutr 2011; 29:371-8. 9. District Health Office, Dadeldhura. Annual Report 2011/2012. Statistics Division, District Health Office, Dadeldhura 2012. 10. Shrestha SK, Banu B, Khanom K, Ali Li, Thapa N, Stray-Pedersen B, et al. Changing trends on the place of delivery:
Why do Nepali women give birth at home? Reprod. Health 2012; 9:25. 11. Shakya S, Pokharel PK, Yadav BK. Study on birth spacing and its determinants among women of Kirtipur municipality of Kathmandu Nepal. Int J Nurs Educ 2011;3:56-60. 12. Gyawali K, Paneru DP, Jnawali B, Janwali K. Knowledge and practices on maternal health care among mothers: A cross sectional study from rural areas of mid-western development region, Nepal. J Sci Soc 2013; 40:9-13. 13. Department of Health Services. Annual Report 2010/11. Management Division, Department of Health service, Ministry of health and Population, Nepal 2011. 14. Pradhan A. Situation of antenatal care and delivery practices. Kathmandu Univ Med J 2005:3:266-70. 15. Pradhan PM, Bhattarai S, Paudel IS, Gaurav K, Pokharel PK. Factors contributing to antenatal care and delivery care practices in Village Development Committees of illam, District Nepal. Kathmandu Univ Med J 2013:11:60-5. 16. WHO. World Health Statistics 2013. World Health Organization, 20 Avenue Appia, 1211 Geneva 2013. 17. Kesterton AJ, Cleland J, Sloggett A, Ronsmans C. Institutional delivery in rural India: The relative importance of accessibility and economic status. BMC Pregnancy Childbirth 2010;10:30. 18. Varma
DS,
Khan
ME,
Hazra
A.
Increasing institutional delivery and access to emergency obstetric care services in rural Uttar Pradesh, India. J Fam Welf 2010;56:23-30.
255
19. Chirdan O, Esther AE. Utilization of institutional delivery services among women bringing their children for BCG in Jos, Nigeria. J Med Trop 2011;13:98101. 20. Devkota MD, Prasai DP, Ghimire J, Jaisawal SK. Responding to increased demands for intuitional child births at referral hospital in Nepal: Situational analysis and emerging options. Family
Health Division, Department of Health services, Teku, Kathmandu, Nepal 2013. 21. Bhusal CL, Singh SP, Bc RK, Dhimal M, Jha BK, Acharya L, et al. Effectiveness and efficiency of aama surakshya karyakram in terms of barriers in accessing maternal health services in Nepal. J Nepal Health Res Counc 2011;9:129-37.
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Inter-District Comparison of Total Fertility Rate in Bihar: Improving Programme Implementation for Better Outcomes Ritu Agrawal1, Bhaskar Mishra2 Amit Mohan Prasad3
Abstract Background: Bihar contributes about 11 percent of the total births (26 million) taking place in the country every year and is characterised by high fertility which is reflected in high crude birth rate (CBR) & high total fertility rate (TFR) and also high density of population. The percentage decline of 13.4% in CBR is the least in the country during 2010-12 over 2000-02. There is significant variation in TFR between Bihar (3.6-Rural and 2.5-Urban) and the national average (2.6-Rural and 1.8-Urban) in terms of rural-urban population. The baseline results (2007-09) from the Annual Health Survey (AHS) show a considerable inter-district variation in TFR (a variation of almost two children between the best and the worst performing districts). Objective: 1.To analyse the plausible factors for the overall high fertility rates of Bihar and the proximate determinants of fertility across districts in terms of better and poor performing districts in terms of TFR . 2.To find out how the state can fast track achieving the goal of population stabilization. Methodology:For the study, data on key fertility and associated indicators such as CBR, TFR, Female Literacy, Institutional Delivery, Total Unmet Need, Infant Mortality Rate etc. has been used from SRS, AHS and Census 2011. Districts were divided into two groups on the basis of their TFR for an easy evaluation. An assessment has also been done to find out the difference in terms of service delivery and awareness among the females about the availability of services. Findings: Group 1 comprising 5 districts reporting the lowest TFR (Patna, Bhojpur, Lakhisaria, Gaya and Jehanabad) shows the high mean female literacy status of 60% as compared to 51% for Group 2 having 5 districts reporting the highest TFR (Sheohar, Khagaria, Saharsa, Kishanganj and Araria); As expected the Group 1 performs well in in terms of indicators which are strongly correlated with TFR and these are institutional delivery (61% against 38% for Group-2, total unmet need (37% against 44% for Group-2) and IMR ( 50/1000 live births against 60 for Group-2). Conclusion and way forward: There is an urgent need to develop district based strategy rather than looking at the entire state through a single lens. Demand generation and improving the service delivery is the key. Spacing of pregnancy & limiting family size shall be advocated to all the women of reproductive age group.
Key words: Fertility, mortality, contraception; accessibility, female literacy, Bihar Background
Bihar contributes about 11% of the 26 million annual birth cohorts in India. The state is characterised by high crude birth rate (CBR), high total fertility rate (TFR)
and high density of population. As per SRS 2012[1], Bihar reported the highest crude birth rate (27.7 against national average of 21.6) and also the highest total fertility
1. Centre for Maternal Newborn Health ,Liverpool School of Tropical Medicine, UK 2. UNICEF, India Country office, New Delhi, India 3. Oil India Ltd, Former Joint Secretary, Ministry of Health & Family Welfare, Govt of India
257
rate (3.5 against national average of 2.4). The difference in TFR in common parlance translates into a difference of almost one child per women. In terms of population density, Bihar ranks first (with1102 persons per sq.km. as against 382 persons per sq.km. for the entire country)as per 2011 census[2] data surpassing West Bengal. With just 2.86 % of landmass of the country, the state has 8.6% share of the country’s population. Bihar being primarily an agrarian economy, the pressure on agricultural land due to increasing population burden has become unsustainable. In line with the recommendation of National Commission on Population (2005), the Ministry of Health & Family Welfare commissioned the Annual Health Survey in 284 districts of 8 Empowered Action Group[3](EAG) states and Assam through the office of Registrar General of India. The results from the baseline survey with reference period 2007-09 and released in 2010-11 reveal considerable inter-district variation in fertility rates in Bihar. It is for the first time that the estimates on composite indicators like IMR and TFR have been made available at the district level from a robust sample (the sample size was based on IMR with 10% Relative Standard Error (RSE) at the district level and more than 16000 households were covered per district on an average in Bihar). The TFR ranges from 2.8 in Patna to 4.7 in Sheohar[4]depicting a gap of about 2 child per women. With 36 out of 37 districts reporting the TFR in excess of 3.0, the state will take several years to reach the replacement level fertility rate of 2.1[4]. With the present pace of population growth, the population stabilisation appears to be a
distant dream in the state of Bihar. Bihar’s percentage of population below 15 years of age is 40.1% as against 30.8% for India[2]. Young dependency ratio for the state[2] is 769 against 510 for the country. Bihar’s demographics are thus extremely important for the demographic transition of the country. At the same time, the demographic situation of the state is extremely important for it to progress on the path of sustainable development. A high fertility rate drives poverty and hunger and increases maternaland child mortality. . Bihar has the Maternal Mortality Ratio of 219 per 100000 live births against the national average of 178[1](TheUnder 5 Mortality rate for Bihar is 57 per 1000 live births against 52 for the country[2]. A high fertility rate and the consequent high population limit available resources to provide good nutrition and changes health seeking behaviour[5]. Sustained high fertility rates lead to disproportionately large populations of young dependents, driving demand for supports for young families, for an adequate number of schools and affordable child care[6]. By emphasizing on spacing and limiting methods of family planning and achieving the same through better utilization of available resources, many states of India have attained the replacement level fertility[1]( 11 out of 20 bigger States). This paper is divided into four sections. This part provides the background of the fertility scenario and its importance in population dynamics of Bihar. The second section talks about the objective and methodology of the study, the third discusses the result obtained from data analysis, and the final
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section gives the conclusion and the way ahead for the state of Bihar for achieving the goal of population stabilization in a focussed manner. Objective The objectives of this study are as follows: 1. To analyse the plausible factors for the overall high fertility rates of Bihar and the proximate determinants of fertility across districts in terms of better and poor performing districts in terms of TFR . 2. To find out how the state can fast track achieving the goal of population stabilization. Methodology Data from SRS 2012[1] was extracted for the state of Bihar and for India on parameters such as crude birth rate, estimated number of ever married women, general fertility rate, etc. Data from Census 2011[2] was also extracted for the state for parameters such as population density, age wise population distribution, etc. This data was assessed for understanding the situation in Bihar vis-a-vis the overall situation of the country. AHS data for 2010-11[4] was used to find out the five best performing and five worst performing districts in terms of TFR. Data for five districts (Group 1) with lowest TFR, viz., Patna (2.8), Bhojpur (3.3), Lakhisarai (3.3), Gaya (3.4)
and Jehanabad (3.4), and five districts (Group 2) with highest TFR, viz., Sheohar (4.7), Khagaria (4.5), Saharsa (4.5), Kishanganj (4.5) and Araria (4.4) was extracted for proximate determinants of fertility such as female literacy, institutional delivery, total unmet need for family planning and infant mortality rate. This data was assessed for analysing the difference between the two groups of districts in the level of service delivery and family planning awareness among females. Table 1 show that Bihar contributes about 11% of the total births in the country. This acquires a different dimension when seen from the perspective that Bihar has been reporting the highest CBR (27.7 per 1000 population in 2012) and TFR (3.5 per women in 2012) in the country for past several years barring one or two years in between. Another development worth noticing is the widening gap between Bihar and other populous states particularly in fertility indicators as they are improving at a speedier rate. The faster population growth coupled with adverse socio-economic situations in the state puts Bihar in an altogether different frame which merits a different lens to examine and understand the dynamics of various concomitant factors responsible for this.
Findings Table 1: Number of estimated births, Bihar and India; SRS 2012[1] CBR
Est. Births
India
21.1
26689126
Bihar
27.7
2966371
259
Table 2: Number of estimated Ever Married Women (EMW 15-49) years, Bihar and India; 2012 (SRS[1] & Census[2]) EMW 244200009 19217619 7.9
India Bihar % Share
Table 3: Fertility rates, Bihar and India; SRS 2012[1]
Crude birth rate General fertility rate Total fertility rate Gross reproduction rate General marital fertility rate Total maritalfertility rate
Total 21.6 80.3 2.4 1.1
India Rural 23.1 87.6 2.6 1.2
Total 27.7 113.5 3.5 1.6
Bihar Rural 28.4 117.3 3.6 1.7
Urban 17.4 61.5 1.8 0.8
Urban 21.6 82.5 2.5 1.2
114.0
122.9
90.2
156.2
160.2
121.7
4.4
4.5
3.9
5.4
5.5
4.6
Table 2 shows that Bihar has about 8% of eligible mothers of the country and bear 11% of the children born every year in the country, which may be one of the highest in the country, and, therefore, reflects the maternal burden and the associated risks they endure in the process.
born to a married woman in Bihar per 1000 live births. The situation as reflected by TMFR remains more or less same as that of TFR, yet the messages emanating across these indicators converge at the conclusion that the fertility in Bihar is on the rise as compared to at the national level.
Though TFR provides a reasonable summary of current fertility levels and is the most appropriate indicator to compare two distinct population groups, it is prudent to examine other fertility indicators such as GFR, GRR, GMFR and TMFR to gauge the entire spectrum of factors governing the fertility behaviour. Table 3 shows that as compared to the fertility pattern at the national level, 33 more children are born to a woman in Bihar per 1000 live births; half a more daughter is born to a woman in Bihar thus widening the reproductive base in the state and 42 more children are
Female literacy rate impacts health indicators, especially maternal and child health indicators including TFR, in a very profound manner. If the woman of the house is literate, she is able to take care of her family members’ health needs in an informed manner. Understanding the importance and association of female literacy with health parameters, Bihar has been giving emphasis on this aspect in the recent years. The scheme under which bicycles are provided to girls for pursuing higher education in Bihar has been very popular in the recent past.
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Such an impact is visible from Table 4 as the TFR for women having studied upto class X has already reached the replacement level not only in urban areas but also in rural areas. Further investment in education can be one of the surest methods to tackle the problem of high fertility. Table 4: TFR, Bihar and India by literacy levels; 2012 Illiterate
TFR-India
TFR-Bihar
Literate Total literate
Without any formal education
Below primary
Primary
Middle
Class X
Total
3.2
2.1
3.1
2.9
2.5
2.2
1.8
Rural
3.3
2.3
3.2
3.0
2.6
2.3
1.9
Urban
2.4
1.7
2.9
2.4
2.2
1.9
1.6
Total
4.6
2.5
3.0
2.8
2.7
2.7
2.0
Rural
4.6
2.6
2.9
2.8
2.7
2.8
2.0
Urban
3.4
2.2
4.3
2.8
2.0
2.5
1.9
Table 5: Better Performing Districts (Group 1) AHS 2010-11[4] Name of District Patna Bhojpur Lakhisarai Gaya Jehanabad Mean
Total Fertility Rate
Effective Female Literacy (%)
Institutional Delivery (%)
2.8 3.3 3.3 3.4 3.4 3.24
69.0 60.9 55.9 58.4 56.5 60.4
72.8 65.2 57.1 43.6 67.7 61.28
From Table 4 and 5, we see that the Group 1districts have a high mean female literacy rate of 60% as compared to 51% for Group 2 districts. Group 1 districts have an average institutional delivery rate of 61% as compared to a low mean institutional delivery rate of 38% for the Group 2 districts. The mean total unmet need for contraception is 37% for the Group 1 districts as compared to 44% for the Group 2 districts. Similarly, Group 1 districts have a lower mean IMR of 50 per 1000 live births as compared to 60 for Group 2 districts. On all the four chosen proximate determinants of fertility, Group 1 districts are found to be performing better
Total Unmet Need for Contraception (%) 24.6 34.9 43.3 38.6 42.3 36.74
Infant Mortality Rate 39 48 53 55 53 49.6
than Group 2 districts. From the two tables, we also see that the best performing district Patna and the worst performing district Sheohar have very wide differential in all the proximate determinants of fertility. The wide differential in institutional delivery percentage (61% vs. 38%) points towards the low level of service delivery in the bad performing districts. By providing adequate health human resource, medical equipments, curb on private practice by government doctors and supervision and monitoring, it should be possible to improve the level of service delivery in these districts. Similarly the difference in total unmet
261
need for contraception also indicates the
utilization of sub-centres and ANMs for
insufficiency of the level of service delivery
service delivery and ASHAs for awareness
in the Group 2 districts even though the
generation can quickly bring down the total
service delivery in the Group 1districts
unmet need in the state, especially in the
also leaves much to be desired. Better
Group 2 districts.
Table 6: Bad Performing Districts (Group 2)(AHS 2010-11[4]) Name of District
Total Fertility Rate
Effective Female Literacy (%)
Institutional Delivery (%)
Total Unmet Need for Contraception (%)
Infant Mortality Rate
Sheohar
4.7
47.7
24.2
45.9
50
Khagaria
4.5
56.4
56.3
35.2
66
Saharsa
4.5
50.6
37.7
38.9
62
Kishangunj
4.5
52.4
34.1
52.5
61
Araria
4.4
49.8
37.7
46.8
61
Mean
4.52
51.38
38
43.8
60
Bihar
3.7
56.3
47.7
39.2
55
IMR is a powerful determinant of family size. Family size tends to be bigger where IMR is high as the couples are not sure about the survival of their children. This is also shown in the data in Table 5 and 6. The mean IMR for the group of districts with lower TFR (Group 1) is 50 per 1000 live births as compared to 60 per 1000 live births for the group of districts with higher TFR (Group 2). Many couples want to limit or space their pregnancies and yet do not use contraception. There are significant barriers to uptake of family planning services. There are a limited number of facilities where people get counseled on birth control information on a daily basis. Barriers such as ethnic and cultural traditions, want for a boy who can provide financial support are still the hurdles. Reduction in TFR will contribute to the economy of the state as 81% of population of Bihar is employed
in agriculture, which is much higher than the national average. Nearly 42 % of GDP of the state (2004-05) has been from the agriculture sector. About 34 % of the state population is below poverty line as against national average of 22%7. Several states (11 out of 20 bigger States), especially southern states, within the country have implemented family planning programmes successfully and have attained the replacement fertility. These states are higher on Human Development Indicator and are making rapid progress on the economic front also. Family planning can directly reduce maternal deaths; reduce exposure to incidence of pregnancy, reduce vulnerability to abortion risks, postpone pregnancies during prematurity of pelvis development by delaying the first birth, and reduce the hazards of frailty from high parity pregnancies. In fact, vulnerability to pregnancy induced complications &
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abortions can be safely avoided by simple use of contraceptives. Globally, contraceptive use averts almost 230 million deaths/year & family planning is the primary strategy for prevention of unwanted pregnancies8, 9. Conclusion and way forward To fast track the requisite demographic transition in Bihar, it would be appropriate to look at the districts as a separate entity for planning interventions rather than looking at the state with a single lens. Onesize-fits-all is not the most appropriate strategy for improving health parameters, particularly in a setting where there are wide inter-regional disparities. Demand generation and improving service delivery are the keys. Appropriate utilization of available resources through supportive supervision and monitoring can go a long way in improving the health parameters in the state of Bihar. Since the demographic transition of India is also dependent on the demographic situation of Bihar in a big way, it becomes crucial for both the state and central government to pay focused attention to the strategy adopted in the state of Bihar. By concentrating on the districts with low health indicators, it should be possible to improve the situation in the state quickly. Strategically, it will be a good idea to pick the low hanging fruits first. Spacing of pregnancy and limiting family size shall be advocated to all women in the reproductive age group. Focussing on supervision of ANMs, ensuring regular service delivery at sub-centres, and awareness generation through better training and utilization of ASHAs should be able to increase the uptake of family planning services. Consequently, it will bring down the TFR of the state. Finally enhanced investment in healthcare will
bring more than commensurate returns for the state and thus for the entire country. References 1. SRS Statistical Report, 2012; Govt. of India, Ministry of Home Affairs; Office of the Registrar General & Census Commissioner; Census 2011: Available at http://censusindia.gov.in/ 2. Census 2011, Govt. of India, Ministry of Home Affairs; Office of the Registrar General & Census Commissioner; Census 2011: Available at http:// censusindia.gov.in/ 3. Annual Report to the people on health, Govt. of India, Sept. 2010 : Available at http://mohfw.nic.in/WriteReadData/l89 2s/9457038092AnnualReporthealth.pdf 4. Annual Health Survey data for 201011: Available at http://censusindia.gov. in/2011-common/AHSurvey.html 5. Community health workers and uptake of family planning in Africa cited at The Lancet Global Health blog: Available at http://globalhealth.thelancet. com/2013/11/14/community-healthworkers-and-uptake-family-planningafrica 6. Coale, Ansley J. (1987). How a population ages or grows younger. In S. W. Menard and E. W. Moen (eds.), Perspectives on Population: An Introduction to Concepts and Issues; Pp. 365-369; Oxford: Oxford University Press 7. Press note on Poverty Estimates 201112, India; Planning Commission. 8. The Global Health series: Family Planning, The Lancet ;edited by the Lancet: released in 2012 : Available at; http://books.google.co.in/
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ge&q=The%20Lancet%20
%E2%80%93%20Family%20 Planning%3A%20The%20Global%20 Health%20series%3B%20edited%20 by%20the%20Lancet%3A%20 released%20in%202012&f=false
9. Saifuddin Ahmed, Qingfeng Li, Li Liu, Amy Tsui; Maternal Deaths Averted by Contraceptive Use: Results from a Global Analysis of 172 countries; Population, Family and Reproductive Health Department; Bloomberg School of Public Health Johns Hopkins University: Available athttp://www. jhsph.edu/departments/populationfamily-and-reproductive-health/_ archive/faculty/Saifuddin%20article.pdf 10. Maternal Mortality Estimates 2010-12, Govt. of India, Ministry of Home Affairs; Office of the Registrar General & Census Commissioner; Census 2011 : Available at http://censusindia.gov.in/
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The Public Health Significance and Issues Related to Noise-Induced Hearing Loss: The Indian Scenario Sharanya Narasimhan*1, Chandru Jayasankaran1, Ramakrishnan Rajagopalan2 C.R.Srikumari Srisailapathy# 1
Abstract Noise induced hearing loss (NIHL) may be due to sudden exposure to loud noise (acoustic trauma) or by chronic exposure to noise (Noise induced hearing loss). NIHL is one of the most prevalent but preventable occupational disorders in the world. The estimated number of persons with disabling hearing loss worldwide is 360 million. The prevalence of Hearing Loss (HL) in adults due to occupational exposure to noise ranges from 7% to 21% in the world. Noise not only affects the hearing but also can have other physical health effects like hypertension, loss of sleep and psychological effects. Methods:Review of literature in the etiology, health effects (both auditory and non-auditory) caused due to exposure to excessive noise, pathophysiology and mechanism, various occupational and non-occupational risk factors, diagnosis, preventive measures, treatment modalities and future research prospects of NIHL Results:NIHL is very common among workers from various Indian industries. There is lack of awareness on NIHL and little education among the workers. The poor socio-economic status of the workers is a major additional factor. Conclusion: NIHL is a serious health problem in India, not by the mere number of affected workers, but also because access to health care services and preventive programs are limited. Lack of awareness about NIHL among employers, employees, and health care professionals is one of the main barriers for the prevention of NIHL in India. Despite the existence of legislation in India, it is not adequately enforced. Thus awareness should be created among the different cadres through educational and training programs.
Key words: Noise, occupational hearing loss,occupational disease, notched audiogram, NIHL
Introduction
hearing loss (NIHL) may be due to (i) sudden
Noise is any unwanted soundand more precisely defined as audible sound that causes disturbance, impairment or health damage. (1)The distinction between noise and sound is very subjective.Noise induced
exposure to loud noise (acoustic trauma) (ii) chronic exposure to noise.NIHL is one of the most common occupational disorders and the second most self-reported occupational illness orinjury.(2)
*Presenting author; # Corresponding Author 1-Department of Genetics, Dr. ALM PG Institute of Basic Medical Sciences, University of Madras, Taramani, Chennai – 116 2- Department of ENT, SRM Medical college hospital and research centre, Katankulathur, Kancheepuram– 603203
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Occupational noise-induced hearing loss is defined as hearing loss that develops slowly over a long period of time (several years) as a result of exposure to continuous or intermittent loud noise.(3) Certain noise standards have been set, exposure beyond which, noise is considered to cause harmful effects on the hearing and health of the worker. According to Occupational and Health Safety Administration (OSHA), the permissible Time Weighted Average (TWA) exposure limit is 90dBA for an 8 hour work shift. The OSHA standard uses an exchange rate of 5 dBA i.e. if the noise level is increased by 5 dBA, the amount of time a person can be exposed to a certain noise level has to be halved to receive the same dose.(4)The permissible exposure limit for noise exposure at work is given in table 1.
and sound levels greater than 115dBis not permitted. (5)According to the Noise Pollution (Regulation and control) Rules, 2000, under the Environment (Protection) Act, 1986 of the Government of India (last amended on 11th January 2010) to control noise pollution: The state government shall categorize the areas in to industrial, commercial, residential, and silence areas / zones. The ambient noise quality standards in respect of noise for different areas / zones have been specified as given in table 2. Table 2: Indian Standards for Ambient Noise levels: Area
Table 1:Permissible Exposure Limit according to OSHA Duration per day Sound level (dBA) (hours) 8 6 4 3 2 1½ 1 ½ ¼
90 92 95 97 100 102 105 110 115
Source: OSHA (57) In India, The Factories Act, 1948 was implemented to regulate the health, safety and welfare of a worker and has to be enforced by the respective state governments. According to the act, a worker can be exposed to 90dBA TWA for 8 hours
Day Time Noise Limits
Night Time Noise Limits
Industrial Area
75 dB (A)
70 dB (A)
Commercial Area
65 dB (A)
55 dB (A)
Residential Area
55 dB (A)
45 dB (A)
Silence Zone
50 dB (A)
40 dB (A)
Source: (58) The estimated number of persons with disabling hearing loss worldwide is 360 million (6)and most of which could have been prevented especially in developing countries.(7)In India, about 63 million people have moderate to severe Hearing Loss (HL) and it is the second most common disability.
7.6% have adult onset HL as
compared to 2% onset in childhood.(8)The prevalence
of
HL in
adults due
to
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occupational exposure to noise ranges from on internet search engines, Pubmed, Google 7% to 21% in the world.(9) scholar etc. in addition to standard ENT and audiology text books. Noise that we encounter in day to day life like traffic noise, noise from gadgets like air Noise levels in India conditioners etc. affects the hearing status and the overall health of people who are not exposed to occupational noise. Prevalence of Hearing loss (7.1%) was seen in selfreportednormally hearing college students that were of high frequency HL type. This may be attributed to use of personal music players and other recreational activities. (10) Noise also has negative effects on children’s learning ability.(11)In a study in the US, the prevalence of noise induced threshold shifts was found to be high among the youth. (12) Exposure to excessive noise during pregnancy has been associated with high frequency hearing loss, intrauterine growth retardation and prematurity and may even result in cochlear damage in newborns when exposed to Neonatal ICU noise.(13)Thus not only exposure to occupational noise but environmental noise also affects the health of humans. Methodology
Some of the occupations that are sources of high noise levels include heavy engineering industry, construction, military, transportation, agriculture, aviation, mining etc.In many developed countries there are strict laws to control noise levels in the industries as well as in the community. Pathophysiology of NIHL Exposure to high intensity noise initially causes a temporary threshold shift (TTS) but with continuous exposure it leads to permanent threshold shift (PTS). Exposure to a very high intensity of noise in a very short duration, for e.g. sudden blast causes acoustic trauma. From various animal studies, it has been shown that exposure to high noise levels causes destruction of the hair cells mainly the outer hair cells of the cochlea as this region is more sensitive to noise than other regions. The initial damage to the cochlear hair cells occurs in the region that perceives sound intensity in the range of 3000 – 4000Hz which is believed to be the weakest portion of the basement membrane of the cochlea. Then the higher frequency regions (6000 & 8000Hz) are affected followed by the lower frequency regions (500 – 2000Hz). Other damages to the cochlea with severe exposure to noise include: decreased blood flow to cochlea, damage to inner hair cells and supporting cells, loss of auditory nerve fibers. (14)
This work gives an overall perspective on the prevalence of NIHL in India and the magnitude of the issue in the Indian context. The health effects (both auditory and non-auditory) caused due to exposure to excessive noise, the pathophysiology and mechanism of NIHL, the various risk factors for NIHL including the genetic susceptibility to NIHL, diagnosis of NIHL, preventive measures, treatment modalities and future research prospects in this Mechanism of NIHL field will also be discussed in this review. In a model proposed by Henderson et al., Referencessourced by performing searches noise can cause increased functioning
267
of the mitochondria present in the hair cells of the cochlea, excitotoxicity at the junctions between the inner hair cells and the nerve fibers of afferent auditory nerve and ischemia/ reperfusion to the cochlear blood flow. All the three pathways may independently cause an increase in reactive oxygen species (ROS) leading to death of the hair cells by either apoptotic or necrotic pathway which is perceived as a cause for hearing loss. (15)
and exposed to high noise levels are at an increased risk of NIHL. (23)
Risk Factors
the
Noise can cause damage to the hearing depending on the following factors:
History of ear infection or head injury also increases the risk of NIHL.(24)Noise has a potentiating effect along with ototoxic drugs like aminoglycoside antibiotics causing death of hair cells there by leading to HL. (25) Individuals who have an underlying genetic susceptibility are also prone to NIHL. In modern
era,
recreational
activities
like listening to music using head phones, frequent visits to discotheques etc. are also
• Frequency of noise – Noise in the range of 2000 to 3000Hz causes more damage than the noise in higher or lower frequencies.
contributing factors to NIHL. Smokers have
• Intensity of noise and duration of exposure – As the intensity of noise increases the permissible limits of duration of exposure should be reduced.
noise exposure. (26)
• Type of noise – continuous noise is more damaging than interrupted noise. • Individual susceptibility – there is a great deal of individual variability in susceptibility to noise.(16) Apart from these some of the other factors include: Occupational risk factors
a higher risk of developing hearing loss than non-smokers with a similar occupational Genetic susceptibility to NIHL It has been clearly proved in animal models that there are underlying genetic factors that contribute to susceptibility to noise. There is an individual variability in susceptibility to noise among humans. But due to lack of replication of results in the various association studies, only a few genes have been associated with increased susceptibility to noise in humans. These include the genes that encode potassium ion channels (KCNE1 & KCNQ4)
Various chemicals like pesticides (17), chemical asphyxiants (carbon monoxide & hydrogen cyanide) (18), organic solvents (Toluene, benzene, xylene etc.) (19), heavy metals (Mercury, lead) (20)have a synergistic effect along with noise. Heat also increases the risk of NIHL.(21)
that have been implicated in deafness;in
Non-occupational risk factors
The polymorphisms in the Glutathione S –
The susceptibility to NIHL increases with age. (22) Workers with hypertriglyceridemia
addition
to
other
monogenic
deafness
genes like Protocadherin 15 (PCDH15) and Myosin 14 (MYO14). Three single nucleotide polymorphisms in the heat shock protein 70 (HSP 70) gene has also been found to be associated with increased risk of NIHL.(27) Transferase (GST) (28)and the catalase gene (CAT)
(29)
belonging to the
oxidative
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stress pathway, have also been associated with increased risk of NIHL. Effects of Noise Auditory effects of noise Exposure to high level noise causes temporary threshold shift (TTS) or hearing loss which recovers gradually after sometime. But repeated exposure to high levels of noise leads to permanent loss of hearing or permanent threshold shift (PTS). Exposure to loud noise is also the most common cause of tinnitus which is the ringing or buzzing sensation in the ear.(30) Non-Auditory effects of noise Various studies have shown a positive association between exposure to occupational noise and increase blood pressure levels.(31-33)High noise levels
have also been attributed to increased risk of hypertension(34-36) and chronic exposures could even lead to myocardial infarction.(37, 38) Adults exposed to noise had difficulty falling asleep and reduced alertness.(39)The major cause of sleep disturbance was tinnitus. (40) It is seen from several studies that, noise has no direct association with mental health although anxiety and depressive symptoms maybe more prevalent among people living in noisy areas or those who are exposed to chronic noise.(41, 42)Annoyance was commonly experienced as a reaction to noise.(43, 44)Some studies have even reported headache,anxiety, nervousness, mood changes etc., after exposure to noise. (51)NIHL could also lead to social isolation and depression in some cases. A model
showing the development of various health effects as a result of exposure to high noise levels is depicted in figure 1.(45) Figure 1: Severity of health effects due to exposure to noise
Source: Babisch, 2002 (45)
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Diagnosis of NIHL NIHL is a silent disability, as the employee and the employer are not aware of its presence until the hearing loss is severe enough to present itself. It does not have any obvious signs or symptoms. Only a periodic audiometric screening would help in early detection of NIHL. The main requirements for the diagnosis of NIHL for medico-legal purpose are (i) presence of high frequency sensorineural HL, (ii) exposure to potentially hazardous noise levels and (iii) high frequency audiometric notch in the audiogram.(46) Generally the presence of a notch at 4KHz is considered as the characteristic sign of NIHL (47) although the notching could be between 3 to 6 KHz as well. (3) Other risk factors mentioned earlier should also be taken into consideration while calculating the HL. Pure tone audiometry is the standard test to measure hearing loss. High frequency audiometry can also be done for early
detection though it is still not yet validated. Audiometry is usually done at the time of employment in many western countries which is the baseline audiometry and then it is periodically repeated to evaluate the HL. Audiometry is usually done after atleast 14 hours of rest period after occupational noise exposure to exclude the effects of TTS. The audiometric characteristic of a NIHL include (3): It is always sensorineural HL Bilateral Notching at the higher frequencies (3000, 4000 or 6000Hz) with recovery at 8000Hz Notch develops at one of these 3 frequencies and may spread to other frequencies with prolonged exposure to noise. A typical 4000Hz notch seen in an audiogram of a noise exposed worker is given in figure 2. Noise exposure alone does not generally result in: (i) HL > 75dB in higher frequencies and (ii) HL>40dB in lower frequencies.
Figure 2: An audiogram showing the characteristic 4000Hz notch in the Right (shown in red) and Left (shown in blue) ear respectively.
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Grading of HL according to WHO recommendations WHO has graded the HL based on the audiometric ISO values are average of values at 500, 1000, 2000 & 4000Hz (Table 4). Grades 2, 3 and 4 are classified as disabling hearing impairment.(48) Table 4: WHO grading of Hearing Loss Grade of Hearing Impairment
Audiometric Performance ISO Value (Better Ear) 0 (No impairment) ≤25dB No or very slight hearing problems, Able to hear whispers I (Slight Impairment) 26-40dB Able to hear and repeat words spoken in normal voice at 1m 2 (Moderate Impairment) 41-60dB Able to hear and repeat words using raised voice at 1m 3 (Severe Impairment) 61-80dB Able to hear some words when shouted into better ear 4 (Profound Impairment) ≥81dB Unable to hear and understand even a Including Deafness shouted voice Source : (48) Degree of Hearing Disability The degree of hearing handicap is calculated as follows (26): i.
The average of hearing thresholds at 500, 1000 and 2000Hz are taken (which is A)
ii.
25dB is then subtracted (upto 25dB is not considered as impairment) i.e. A-25
iii.
This is then multiplied with 1.5 i.e. (A-25)x1.5 (This gives the hearing impairment for that ear)
iv.
Similarly the percentage of hearing impairment is calculated for the other ear.
v.
The percentage handicap of an individual = [(better ear% x 5)+worse ear%]/6
Treatment prospects
for
NIHL
and
future
NIHL is a very complex disorder involving both the environmental and genetic factors. Since there is a great deal of individual variability in susceptibility to noise, genetic testing plays an important role in personalized treatment for NIHL. Various treatment strategies have been devised. The most common strategy is the use of antioxidants to neutralize the ROS. Various principal compounds like allopurinol, N-acetylcysteine and methionine have been tested using animal models and were found to have protective effect against NIHL. Antioxidant enzyme like Glutathione peroxidase (GPx) and oral intake of Magnesium have also been found to be effective against NIHL.(49) Apart from these, a lot of research is underway to
271
regenerate cochlear hair cells using stem cells and gene therapy.(50) Researchers are also trying to use nanotechnology to deliver antioxidants or genes to treat NIHL.(51) Even though a lot of research is underway, there is no established treatment for NIHL so far. Use of a combination of strategies may be more effective. Since NIHL once acquired is irreversible, prevention is the best option until some strategy is devised for personalized treatment of NIHL. Prevention Generally in an occupational set up, hearing conservation programs (HCPs) are implemented with the main aim of preventing occupational NIHL, that involves the following (52) as shown in figure 3: • Noise monitoring – Involves Identifying the source of noise, evaluating the risk involved and implementation of
•
•
• •
•
•
•
engineering controls to reduce the risk. Audiometric testing – Annual audiometric testing to detect early hearing loss Audiometric test requirements – use of audiometer and specification for sound proof room for audiometric testing Audiometric calibration – Periodic calibration of audiometer Hearing protectors - Providing suitable hearing protectors and ensuring the proper use of the hearing protectors by persons exposed to excessive noise Evaluation of audiograms – Comparison of present audiogram with base line audiogram to detect any shift. Training - Training and educating persons involved in the HCP to raise their awareness of noise hazard and prevention of NIHL Record keeping - Keeping records of the measures taken.
Figure 3 - Flowchart showing the various steps involved in a Hearing Conservation Program
Source:(52 ) http://www.mom.gov.sg/Documents/safety-health/Guidelines%20on%20Hearing%20Conservation%20Programme.pdf
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NIHL: The Indian Scenario As mentioned earlier, noise levels in Indian industries are mostly found to be higher than the stipulated 90dBA. In a study by R. Bedi(53) on two textile plants in North India, the sound levels were found to be between 80 and 102dBA. Similarly in oil and rice mills also the noise levels ranged between 78-92dBA. (54, 55) In the forging units of small scale industries the noise
levels range from 86.5 to 110dBA. (56) Table 3 shows some of the sources of noise with emphasis to the Indian scenario. Apart from the noise levels the number of hours of exposure per day and the number of working days per week are also more in India. (53) Thus NIHL is common among the workers of the various industries. The prevalence of NIHL among the various industries is also given in table 3.
Table 3: Noise levels in different Industries and Prevalence of NIHL in India Type of industry/ Source of Noise Air force
Police (P) & Traffic police (TP)
Textile mills Cotton Ginning Industry Lock factory Ship Building Industry
Noise levels Max-109.3 (dBA)
No. of workers/ participants 229
-
1000
-
421
87.9
50
-
228
89-106dBA
180
82-104dBA
114 276
There are no specific provisions for noise control in the Indian Factories Act. Noise induced hearing loss is only mentioned as a notifiable disease. Most of the workers belong to the unorganized sector and are not protected by any legislature. There is availability of cheap labors due to high rates of unemployment. Other issues include shortage of trained and skilled occupational health professionals. A large number of occupational injuries and
Audiometric findings 6KHz Notch-57.3% 4KHz Notch – 34.3% 22.9% had NIHL 81.2% - Had raised hearing thresholds 62.3% had mild HL & 37.7% had HL >40dB HL 84% had HL
Study Satish &Khashyap, 2008 (59) Nair &Khashyap, 2009 (60) Singh & Mehta, 1999 (61)
Ingle et al., 2005 (62) 33.7% had NIHL Ruikar et al, 1997 (63) 96% had some HL Dube et al., 2011 (64) 45.61% had NIHL Singhal et al., 2012 (65) 6% had NIHL Bhumika et al., 2013 (66)
illnesses go undetected or unrecognized due to lack of awareness, production pressure and negligence of the workers and the management respectively. The workers seldom use any protectors against loud noise either due to lack of awareness or carefree attitude. It should be made mandatory by the respective managements before work is started every shift. Finally, there is no clear policy on occupational health as a whole.
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Conclusion NIHL is a complex disorder and requires a multifactorial approach. Even though lot of strategies is being developed to treat NIHL, the best probable intervention is prevention. Hearing conservation programs have been enforced in industries where the noise levels are very high. Occupational NIHL is a compensable disease in many countries including India. In our country, there are few stringent laws and ineffective enforcement to protect the workers. There is lack of awareness among the workers and the owners alike. The economic status also forces the workers to continue in the job in developing countries even if they are aware. NIHL is the very much preventable, but once acquired it is irreversible. Conflict of Interest: None Acknowledgements: This work is supported by an ongoing Tamil Nadu Pollution Control Board Grant (2013 -2015) to CRS. References 1. Good practice guide on noise exposure and potential health effects. 2010. 2. UNITED STATES OF AMERICA Noise Induced Hearing Loss Statistics 2008 [10.01.2014]; Available from: http://www.nfd.org.nz/site_resources/ library/OrganisationFiles/Research/ Hearing_Stats_USA.pdf. 3. Kirchner DB, Evenson E, Dobie RA, Rabinowitz P, Crawford J, Kopke R, Hudson TW. Occupational Noise-Induced Hearing Loss. JOEM. 2012;54(1):106-8. 4. Occupational [10.01.2014];
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59. Satish, Khashyap R. Significance of 6 khz in noise induced hearing loss in Indian Air Force Personnel. Ind J Aerospace Med. 2008;52(2):15-20. 60. Nair S, Khashyap R. Prevalence of Noise Induced Hearing Loss in Indian Air Force Personnel. Medical Journal Armed Forces India. 2009;65(3):247-51 61. Singh VK, Mehta AK. Prevalence of occupational noise induced hearing loss amongst traffic police personnel. Indian J Otolaryngol Head Neck Surg. 1999;51(2):23-6. 62. Ingle ST, Pachpande BG, Wagh ND, Attarde SB. Noise exposure and hearing loss among the traffic policemen working at busy streets of Jalgaon urban centre. Transportation Research Part D: Transport and Environment. 2005;10(1):69–75. 63. Ruiker MM, Motghare DD, Vasudeo ND.Evaluation of Hearing handicap in textile mill employees with noise induced hearing loss. Indian J Otolaryngol Head Neck Surg. 1997;49(2):97-100.
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GLOBAL PUBLIC HEALTH CONFERENCE 2014
The Contours of public‘Wellness’: In the Context of Tourism S. Rajamohan
Abstract Hospitality Industry is an important segment of Tourism, where the tourists are catered with food and accommodation. In a given destination, the public i.e., the host community play a pivotal role in showcasing the resources of the tourism destination. Hence, the locals, tourists and the Hospitality industry play an inseparable role in fostering the tourism in a given destination. In recent years there had been a paradigm shift from consumerism of the destination to care and well-being of the locals and tourists in a destination. Tourists’ destinations are now focusing to offer and promote physical and mental health for the locals and tourists rather than mere pleasure. Destinations are now preparing to exhibit ‘eudaimonia’ which is a contented state of being happy, healthy and prosperous rather than only being ‘hedonistic’ which is offering happiness alone. This paper analyses the ‘well-being’ or ‘wellness’ products of a destination and appraises the participation of the Hotel Industry in applying the same to the locals and tourists. Rich theoretical inputs from various sources are incorporated, to enhance the applicability of the paper.
Introduction Tourism as a product and service oriented industry capable enough to generate widespread benefits and impacts to the general public and economy. Especially the wellness tourism or well-being tourism is a fastest growing market for the tourism industry. At times people gets confused with the term medical tourism and Wellness tourism. Sometimes these two terms are used interchangeably, but these two terms are entirely different. We can say that medical tourism is where people travel to other countries to receive discounted medical care or procedures that are not available in that country where as wellness tourism is travel allied with the quest of maintaining or enhancing one’s personal wellbeing.
According to the Global Wellness Tourism Economy Report 2013, Spa experiences, healthy eating, opportunities for personal growth, yoga and meditation, fitness, stress reduction and holistic health are among the experiences sought by wellness travelers travelling across the World. Industry executives are well advised to offer services and options that meet the wellness travelers’ needs. A number of hotel brands had already started offering services with healthy rooms, Better Meals, fitness centers and even yoga classes. A growing number of wellness retreats and spas are cropping up across the tourism destinations. But the main issue here is whatever wellness facilities are being offered all are tourist centric we forget the most important component of Tourism industry i.e. local public. The local public
Institute of Hotel Management Catering Technology & Applied Nutrition, Chennai
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or host community plays an important role in fostering tourism in a given destination so health of the local public is not merely the responsibility of the healthServices, but it is also the responsibility of the tourism sector to ensure public wellness and to achieve Millennium Development Goals (MDGs) predominantly those concerning environmental conservation and Public Health. Various wellness facilities are offered in hotels or at tourist destinations but only tourist or guest have the privilege to utilize those facilities whereas the local public or staff in the hotels have limited or no access to these facilities. So there is a need to create enough public health infrastructures around all the tourism destinations where even local public should have privilege to utilize those facilities and a community culture can be created which can boost physical and mental health of the tourist and local public equally. Objectives The main objective of this study is: • To analyse the possibility of bringing Tourism and Public Health on the same platform. • To develop public health infrastructures in tourism destinations. • To involve the tourist and public in the phenomena of developing wellness centers in tourism destinations. Methodology As this study is a vital issue in the field of hospitality, the paper relies mainly on the primary sources. Well thoughtout questionnaires and various interview schedules have been used and sample
includes Tourist, General public, General Manger of the Hotels/Resorts and Staffs of the various Hotels. Review of Literature Tourism and public wellness both are inter related. Public wellnessis “promoting health all the way through the well thought-out efforts, the art of preventing disease, and au fait choices of society, organizations, communities and individuals. Promoting public wellness is a complex task but one than can be aided by other professionals(1). The developing view of public wellness is to reject the idea of ourselves as mechanics, agents that can diagnose and fix what is wrong. Instead we understand ourselves as gardeners, looking at what nourishes human life and spirit(2). Wellness has to do with quality of life. In a holistic approach to health (Chinese, ayurvedic and integrative medicines), wellness treatments and therapies restore the vital balance among bodies, mind, and spirit toward equilibrium and health harmony (3). Normally the local people residing in and tourist destinations are not aware about wellness treatments, various therapies, yoga and the hygiene standards which they should follow because they are not academically qualified; they do the job since they hadgained experience in their trade over the period of time (4). So the most important thing is to create the awareness amongst the people through various ways like taking initiative under “Campaign Clean India”, enrolling people in Hunar se Rozgar Scheme sponsored by Ministry of Tourism, Government of India conducted at Institute ofHotel Management and at various star category hotels where they give ample information and training on hygiene and standard procedures.
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Campaign Clean India: An Illustration “Campaign Clean India” this is one of the way through which we can ensure fostering public health at the tourism destinations. “The Clean India campaign has been initiated by the Ministry of Tourism, Government of India with the objective to increase tourist arrivals to the country and to improve the Public health, quality of services and provide a hygienic environment in and around tourist destinations across the country,” Various hospitality Industry Organizations can take a responsibility of maintaining aesthetic upkeep of a particular tourism destinations under their Corporate and Social Responsibilities (CSR) (5) e.g. ONGC has taken up the maintenance of the TajMahal complex (A world Heritage Site.) as a part of its corporate social responsibility. A similar initiative was taken by Students, Staff and Principal of the Institute of Hotel Management Catering Technology & Applied Nutrition, Chennai. They went all the way from Chennai to Mamallapuram (a World Heritage Site), and cleaned the premises, and created awareness about hygiene and sanitation (fig.1, 2, 3, 4).
Fig – 3
Fig – 4 Data Analysis A brief investigation was made with the tourists at Mahabalipuram (A world Heritage Site). Almost around 60 foreign tourist and 30 domestic tourists were interviewed while gathering the information it was observed that most of the tourists give priority to the wellness facilities.
Fig – 1
Fig : 5 Source – Primary Data
Fig – 2
A brief investigation was made with the local public near the Marina Beach and Mahabalipuram and the staff of the
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various hotelsas well. It was found that general public are not aware of the Hygiene standards and many of the hotel staffs were not academically qualified so it was very difficult to implement hygiene standards.
Suggestion 1. The people should be given ample information and training on hygiene and standard procedures which should be an on-going process and it will help in implementing hygiene & sanitation standards in the society (6). 2. Various initiatives can be taken by the hotels and other Hospitality industry organization to create awareness amongst the people and to keep surroundings clean and hygienic under “Clean India Campaign”.
Fig – 6 Source – Primary Data General Manager of the hotels/resorts was interviewed about their perception and steps taken towards the improving public health and promoting wellness tourism. The data collected are given below: Fig : - 7 Source – Primary data
3. Public health infrastructures such as spas, well equipped fitness centre,holistic health centers can be established in and around the entire tourist destination which will help in fostering public wellness (7). 4. Yoga and meditation classes can be conducted by various hospitality organizations for the local people under their corporate and social responsibilities (CSR). 5. The local public should be brought under ‘Huner Se Rozgar’scheme sponsored by Ministry of Tourism, Government of India conducted at Hotel Management institutes and star category hotels where personal hygiene and other sanitation standards are taught in the classes. Conclusion
From the above data it is evident that Hotels/resorts have taken various steps to promote wellness tourism and ensuring public health under their corporate and social responsibilities (CSR) but they are mainly concentrating on tourist. They need to concentrate on staff and tourist equally.
It has been observed that in any tourism destination the local public and local tourist play a pivotal role in showcasing the resources of the tourism destination. So there is a need of creating public health infrastructure in and around tourist destinations and bringing local strategies for tourism and public health together and
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community culture can be created where the tourist destination is seen to enhance and promote physical and mental health not only for tourists but for locals also.
4. D. Wanless. Securing our future health: taking a long term view, London: HM Treasury. 2002.
References
5. R. Bushell and P. J. Sheldon. Wellness
1. M. Smith and Laszlo. Health and Wellness Tourism.2009.
6. Jayshankar
2. P. E. Cooper and M. Cooper. Health and Wellness Tourism: Spas and Hot Springs. Channel View Publications. 2009. 3. M. Smith, N. Macleod and M. H. Robertson. Key Concepts in Tourist Studies. 2010.
and Tourism: Mind, Body, Spirit, Place. Gupta.
Interview
with
General Manager, MGM Beach Resort Chennai. 11th January 2014. 7. KarolyeneDevis. Interview with training Manager, TAJ Gateway, Chennai. 14th January 2014.
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Impact of Internet Addiction on Physical Health, Mental Health & Social Well Being of college students in Bengaluru, the Silicon Valley of India
Sharmitha K, Satish Kumar Abstract Context: Research findings have highlighted that excessive use of Internet adversely affects one's physical & mental health and social well being. Aims: In college students, to determine the impact of Internet addiction on physical health, mental health and social wellbeing. Methods and Materials: In total, of 554 data samples from 8 colleges selected through multistage cluster sampling, 515 samples were analysed. Young’s 20 items Internet Addiction Test; an inventory including demographic factors was administered. The level of Internet addiction was determined based on the Young’s internet addiction scale; students were classified as mild, moderate and severe addicts. Physical Health and Social wellbeing status was assessed by self reported measures. Mental Health status was assessed using GHQ-12. The associations between the students' levels of Internet addiction and physical health, mental health and social wellbeing were analysed using descriptive statistics. Results: This study in 16-26 years (mean ± SD 19.2 ± 2.4 years), with marginally high female representation (56%) identified 34% (95% C.I 29.91% - 38.09%) and 8% (95% C.I 5.97% - 10.63%) as students with mild and moderate internet addiction respectively. Backache (OR1.72, 95% CI -1.129-2.618, p=0.034), weight gain (OR-3.78, 95% CI -1.457-9.849, p=0.004), Joint pain (esp. Wrist) (OR-1.95, 95% CI -1.051-3.629, p=0. 032), sleep disturbance (OR-2.61, 95% CI -1.683-4.052, p=0. 000) were significantly higher among those who presented with internet addiction. The findings demonstrated that students with internet addiction had compromised mental health status along with relationship problems (OR-2.45, 95% CI -1.461-4.129, p=0.001), being withdrawn, aloof and decreased interaction (OR-2.79, 95% CI -1.356-5.751, p=0.004), not taking up newer responsibilities (OR-2.42, 95% CI -1.326-4.417, p=0.003)and non completion of assigned task (OR-2.03, 95% CI -1.235-3.343, p=0.005) and poor academic performance (OR-3.37, 95% CI -1.871-6.098, p15 suggested states of distress and Scores >20 suggested severe problems and psychological distress. Statistical Analysis The SPSS version 17.0 was used for statistical analysis of the data collected. Socio demographic Variables have been denoted by frequency tables, Prevalence of internet addiction described in terms of percentage, the associations between the students' levels of Internet addiction and physical health, mental health and social wellbeing were analysed using a chi-square test. In all calculations, p values below 0.05 were considered significant.
Results The cross-sectional study was carried out in 8 different colleges across different streams (arts, science, and computer) in the city of Bengaluru during the period of June – July 2013. It covered about 600 college students aged 16-26 years. Study participants were from graduate and post graduate colleges. Of the total 600 students, 554 returned the filled questionnaires, around 10 could not be included in the study as they were not using the internet, and 29 had submitted forms which were incomplete. Thus, a total of 515 students were finally included in the study. Of the studied sample, 56% were females. College approval and written informed consent were obtained for all students who participated. The study was approved by the SRM School of Public Health Ethics Committee. A pilot study was done on 20 students; suggestions were incorporated before the start of the study. As presented in the table 1, Mean age of students who participated in the survey was 19.2±2.4 years; with a marginally higher female representation (56%). Though the high number of students participated from the 1st and 2nd years, there was almost a uniform representation of degree, professional and preuniversity colleges. The majority of the students were day scholars commuting from their residences and have been educated in an English medium. Mothers of the participants were mostly housewives and fathers working in public and private sectors. With absolutely no prevalence of severe Internet addiction, moderate levels of addiction seem to be on par with what has been reported in literature in the same population at other places and mild
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addiction which is the at risk population on the higher end. The exact findings have been reported in table 2. Backache (OR-1.72, 95% CI -1.129-2.618, p=0.034), weight gain (OR-3.78, 95% CI -1.457-9.849, p=0.004), Joint pain (esp. Wrist) (OR-1.95, 95% CI -1.051-3.629, p=0. 032), sleep disturbance (OR-2.61, 95% CI -1.683-4.052, p=0. 000) were significantly higher among those who presented with internet addiction. The findings demonstrated that students with internet addiction had compromised mental health status along with relationship problems (OR2.45, 95% CI -1.461-4.129, p=0.001), being withdrawn, aloof and decreased interaction (OR-2.79, 95% CI -1.356-5.751, p=0.004), not taking up newer responsibilities (OR2.42, 95% CI -1.326-4.417, p=0.003)and non completion of assigned task (OR-2.03, 95% CI -1.235-3.343, p=0.005) and poor academic performance (OR-3.37, 95% CI -1.871-6.098, p
