MORBIDITY PROFILE OF UNDER FIVE CHILDREN RESIDING IN BARBOTE VILLAGE DEVELOPMENT COMMITTEE OF ILAM DISTRICT OF EASTERN NEPAL Affiliation

Sharma KR, Dawadi S, Upadhaya P, Khanal VK, Singh SB. Morbidity Profile of Under Five Children Residing in Barbote Village Development Committee of Ilam District of Eastern Nepal. BJHS 2018;3(3)7: 554-559 * Corresponding Author Dr. Khem Raj Sharma Assistant Professor School of Public Health & Community Medicine B. P. Koirala Institute of Health Sciences, Dharan Email: khem.sharma@bpkihs.edu ORCID ID: https://orcid.org/0000-0001-6979-1742 ORA 89 ABSTRACT


Methodology
A community based cross-sec onal study was conducted among all the eligible under five children of Barbote VDC of Ilam District for two weeks from 16-30 March, 2016.Face-to-face interviews were conducted with the legal guardian/ caretaker of the children with pre-tested, semi-structured ques onnaire.Calibrated & validated equipment were used for simple biophysical measurements.Odds Ra o (OR) with confidence limit was calculated to examine the strength of associa on between the variables with the probability of significance set at 95% of Confidence interval (CI).Ethical permission was taken from the Ins tu onal Review Commi ee (IRC) of BP Koirala Ins tute of Health Sciences, Dharan.

Results
Of the total 406 under-five children studied, 35.5% complained of illness such as acute respiratory infec on, diarrhea and fever within the past two weeks.Regression analysis by the backward condi onal method disclosed the fact that children of households with low socioeconomic status and those using biomass fuel for cooking were significantly associated with presence of illness.

Conclusion
More than one-third of the under-five children in BarboteVDC of eastern Nepal were found to be ill mostly due to preventable causes.Factors significantly associated with the presence of illness included the use of biomass fuel and low socio-economic status.

INTRODUCTION
In 2017, the under-five mortality rate in low-income countries was 69 deaths per 1000 live births-around 14 1 mes the average rate in high-income countries.Children cons tute a vulnerable group and are the leaders of the future.So it becomes important for each na on to safeguard and promote the health of its children.Morbidity status of children under five is an important index of the health status of a community.
The health status of children in Nepal has improved over the 2 last decade with the a ainment of MDG targets.However, developing countries like Nepal s ll have a long hurdle to cross to promote the health status of its future genera ons.With the incorpora on of child health programs in the na onal health system, the under-five mortality has been reduced to 3 33.7/1000live births, which is s ll very much high.
First five years of life is a transi on phase for the child from the mother's womb to the social pla orm.It is a very crucial phase as physical, psychological and social growth and development are intensively ongoing in this period.This requires adequate amounts of quality nutri on and various other resources.Lack in any one resource could result in grave consequences with irreversible damage that could 4 compromise their poten al in later life.
Nepal Government rou nely collects data on Under-five children a ending the Government Health Facili es through the Health Management Informa on System and 5 publishes it in the form of Annual Report.However, this report is incomplete as it misses those children a ending the private sector or in the community and does not give a complete picture of the situa on.In the present day world, accurate data is required for the implementa on of measures for management of health condi ons.Studies done in the community give a clear picture of the real situa on to aid in priori zing the applica on of methods for preven on & control.So, this study was conducted to assess the morbidity status of under-five children and its associated factors in Barbote Village Development Commi ee (VDC) of Ilam district of eastern Nepal.

METHODOLOGY
A community based cross-sec onal study was conducted for two weeks dura on, from16 to 30 March 2016, among under five year old children in all the nine wards of Barbote 6 VDC of Ilam district with an under-five popula on of 416.This was a census study where a total of 406 children were enrolled from all wards covering 97.6% of the under-five 6 popula on of Barbote VDC.The remaining children were either unavailable even a er 3 visits, or did not give consent for the study.
In each eligible household, the nature and purpose of study was clearly explained and an informed wri en consent was obtained.Face-to-face interviews were conducted with the adult legal guardian/caretaker of the child from the eligible households with a pre-tested semi-structured ques onnaire.The data collec on tool consisted of socio-demographic sec on, birthing and feeding prac ces of the child, housing environment and clinical profile.Calibrated and validated equipment were used for simple biophysical measurements like height and weight and other parameters were assessed using standardized protocols.All children below 60 months were included except those who did not provide consent.

Opera onal defini ons
Illness was defined as a period of sickness affec ng the body at the me of visit or within 2 weeks prior to it, based on the Community Based Integrated Management of Neonatal and 7Childhood Illness (IMNCI) guidelines of Nepal.IMNCI primarily includes Acute Respiratory Infec on (ARI), Diarrhoea, Fever and Nutri onal status assessment.Overcrowding was defined as less than 70 square feet of floor space area per person in the household.Floor space area refers to total floor space area of all the sleeping room 8 in house divided by the number of family members.Pucca houses are made from high quality materials, i.e. bricks, cement, concrete, including roof, walls and floor while katcha houses are made from mud and thatch or other low quality materials.Semi-pucca houses are made from a 9 combina on of the above types.This study considered family size, overcrowding, cross ven la on, type of house, natural ligh ng, and type of cooking fuel as proxy measures for housing condi ons.Those households with per-capita/day less than 10 1.90$ was considered as being below poverty line.
Bivariate analysis with chi-square tests were done to find the sta s cal significance between two or more categorical variables.Odds Ra o (OR) with confidence limit was calculated to examine strength of associa on between the variables.Logis c regression analysis by the backward condi onal method was performed for all independent variables whose probability was less than 20% in the bivariate analysis.This was done to iden fy associated factors for morbidity in under five children with the probability of significance set at 95% of confidence interval (CI).Ethical permission was taken from the Ins tu onal Review Commi ee (IRC) of B. P. Koirala Ins tute of Health Sciences.Permission was also taken from the local authority of Barbote VDC.The children found to be ill during the study were managed at the local health centre.

RESULTS
The distribu on of 406 under five children in the various wards of Barbote VDC is depicted in figure 1.Nearly 81.5% of the mothers of under-five children were 20-30 years of age, almost 40% had completed secondary level educa on and only 5.4% were illiterate (Table 2) of the total 406 children, 88.4% delivered in Hospital, 80% had undergone normal delivery and 4.7% were pre-term deliveries.Only 4.4% of the children had low birth weight, while 4.7 were overweight at birth.Over 95% of the mothers had fed colostrum to the child while only 53.4% had undertaken exclusive breast feeding prac ces.Regarding immunisa on status, 99.8% and 88.2% had received BCG and Measles respec vely.Of the total 274 children of 2-5 years age group, all (100%) had been fully immunized.

Table 2: Birthing Characteris cs and Immunisa on Status (n=406)
A good propor on of the study subjects lived in a Katcha type of house (44.6%) and overcrowding was present in around 20% of the households (Table 3).Almost all (>98%) households boiled water for consump on and around 54% s ll used Biomass fuel for cooking.Distance of latrine from the water-source was less than 15 meters in 62.3% of the households, while majority of the households (88.9%) had a water-seal type of latrine.At least one cigare e smoker was present in 13.5% of the households visited.

Table 3: Housing and Environmental Characteris cs (n=406)
A total of 35.5% of the under-five children gave a history of illness within the past two weeks with 23.7% complaining of ARI and 5.2% had diarrhoea.(Table 4)

Table 4: Clinical Characteris cs of under five children (n=406)
Bivariate analysis disclosed that under five children aged less than 3 years, belonging to Janaja ethnicity, low socioeconomic status and use of Biomass fuel for cooking were significantly associated with presence of illness (Table 5).However, a er adjus ng for other variables, Low socioeconomic status [aOR=2.1:95%CI (1.32-3.34);p=0.002] and use of Biomass fuel for cooking [aOR=1.6:95%CI (1.03-2.37);p=0.036] were found to be significantly associated with the presence of illness in the under-five children (Table 6).Nepal.Similarly, a study done in Ethiopia also found similar 12 prevalence of ARI.This brings us to an inference that morbidity and mortality in under five children has decreased significantly in the recent years.However, the reported prevalence is s ll high, as these are preventable condi ons that impart a large burden on the already overstretched health system of a developing country like Nepal.
On bivariate analysis, children less than 3 years were 1.5 mes more likely to fall ill than older children [OR: 1.55; CI (1.03-2.34)].Similar findings have been seen from studies around the world, as younger children are more suscep ble [13][14][15] to various pathogens.
However, a hospital based study done in Kathmandu, Nepal reported that older children 16 are more prone to ARI than younger ones.One possible reason for this could be the fact that older children voice their signs and symptoms more clearly than young ones and thus have more chances of visi ng hospitals, resul ng in higher use of hospital indoor/outdoor services.However, this finding did not remain significant a er adjus ng for other variables in the present study.
Lower levels of educa on of the mother has also been implicated in morbidity of under-five children in various 14,15 studies.However this study did not find any significant associa on.
In this study,based on the classifica on of Nepal Demographic The chances of disease and ill health are more in lower socioeconomic status (SES) popula on.Similarly in this study, using the modified Kuppuswamy socio-economic scale to assess this parameter revealed the fact that being in the low SES predisposed the child 2.1 mes more for illness compared to the middle or upper SES [adjusted OR: 2.1; CI (1.35-3.4)].This was significantly associated even a er adjus ng for other variables in the regression analysis.21 Similar results were seen in studies done in India and Brazil.The ability to afford and provide for resources in a household is one of the determinants of the health status of its members.So low SES households cannot afford to provide for quality nutri onal food and health care in the required amount for its members that predisposes them to illness.The three delays (seeking care, reaching care and receiving care) are accentuated due to the lack of resources of the low SES popula on.
This study found 54.2% of the households of Barbote VDC using Biomass fuel for cooking.Under-five children in those households were found to be 1.61 mes at more odds of developing illness than children in households that used other forms of fuel.This remained sta s cally significant even a er adjus ng for other variables [adjusted OR: 1.61; CI (1.07-2.43)].A study done in Dhading District of Nepal found 87% of households using solid biomass as a primary source of fuel resul ng in a total of 1284 Disability Adjusted Life Years (DALY) lost due to ARI and pneumonia and about 50 percent of it was a ributed to indoor air pollu on in the 23 household.Indoor air pollu on due to biomass fuel is a major risk factor for morbidity as previously shown by 12,14,15,16,21 various studies.
Use of alterna ve cleaner fuels, educa on about effects of smoke on children in the household, and procedures to ven late the room could be some of the few measures to reduce its health effects on children.

CONCLUSION
Although, morbidity and mortality in under five children has decreased significantly in the recent years, the reported prevalence of 35.5% is s ll high, as these are preventable condi ons that imparts a large burden on the already over stretched health system of a developing country like Nepal.Low Socio-economic status and use of Biomass fuel for cooking were found to be significantly associated with the presence of illness in under five children of Barbote VDC, Ilam.

RECOMMENDATIONS
These preventable condi ons, have simple and effec ve solu ons.Behavioral Change Communica on (BCC) ac vi es should be employed to reach the popula on, far and wide, on the alterna ves to biomass fuels.Use of cleaner fuels should be advocated at the na onal level along with adequate counselling of the guardians during the health post visit regarding biomass use and effects of indoor air pollu on.Child to parent advocacy, a new concept of inculca ng habits and behaviors, should be prac ced through schools by inclusion of these subject ma ers in the curriculum with prac cal demonstra ons.

LIMITATION OF THE STUDY
Addi onal measures like rou ne lab inves ga ons of the ill children to supplement the study tools would have provided a more comprehensive picture of the overall health of the children, but was not possible due to limita on of resources.

17 and
Health Survey 2001, children of hill Janaja ethnicity were found to fall ill 1.5 mes more compared to other ethnici es [OR: 1.53; CI (1.02-2.3)].Social determinants, habits, tradi ons and customs increase the risk of infec on among Janaja children, since these families tend to be larger and live in more crowded condi ons.The Na onal Legal Code (Muluki Ain) proclaimed in the period of autocra c Rana rulein 1854 AD categorized them as nonenslavable matwali (liquor drinkers) based on their fondness 1 8for alcohol.Similarly, a study on transmission of tuberculosis infec on to under-five children in household contact in Sunsari District reported that hill janaja children under five years of age were 2.5 mes more likely to be Mantoux test posi ve -a proxy measure of transmission of 19 Tuberculosis infec on.Data from the NDHS 2001 show that access to and use of a range of health and family planning services is consistently lower among Dalit and 17 most Janaja women.Literature also suggests that varia ons in individual health service u liza on behavior is 20 culturally condi oned.These factors could pose addi onal risks for the hill janaja children in comparison to other ethnicity children.However, this significance was lost in the regression analysis.

Table 6 :
Logis c Regression Analysis