Data and Methodology

The data for this study is taken from National Family Health Survey-3 (NFHS-3). Interviews were conducted with 124,385 women age 15-49 and 74,369 men age 15-54 from all states. The information about children’s was obtained from mothers of children under five years. Thus a total sample of 56,438 children was obtained. For the purpose of estimating ARI prevalence children whose mothers reported a episode of cough with rapid breathing  during the last two weeks are presumed to have an experience of ARI infection. If mother’s response was positive, mothers were further asked symptoms of illness/sickness. Any public or private health care facility, doctor community health worker are considered as appropriate sources of advice or treatment whereas pharmacies, shops and traditional practitioners are considered to be an inappropriate source. Since a child might have experienced two separate illness episodes in the past two weeks, one with a cough and rapid breathing (ARI) and other with a fever, it is not possible to determine for children with both conditions reported whether the care was sought for the ARI. However, fever occurs at point of time in majority of cases of ARI. Hence, in this study prevalence of treatment seeking has been calculated with the denominator of children who have suffered from ARI and/or fever. Bivariate and multivariate techniques have been applied to ascertain the effects of predictor variables on the response variable.

Pattern and Prevalence of ARI

Social and medical scientists have clearly established the association between the various characteristics of socio-economic factors and prevalence of illness in a population and within its different groups.  These factors however, not only affect the occurrence of illness, but they also play a vital role in determining its pattern. For instance adequate knowledge of background characteristics of child population being studied may provide an insight of the pattern of morbidity, one should expect. According to Perk, “a knowledge of the community and its population is just as important for successful public health work as is the knowledge of epidemiology and medicine”. Great emphasis has been placed on poor household environmental quality as a cause of high morbidity among children under age five.

Therefore, examining the background characteristics of child, in relation to our focus of interest (morbidity variables), will obviously enable us to make better assessment and care and consequently will enhance our understanding of the   substantive findings in the study. Therefore consideration will be given among other things, to the demographic (age of child, sex, birth order), as well as socio-economic and environmental characteristics of the study population.

Prevalence of ARI by Background Characteristic

Infections of the respiratory tract are perhaps the most common human ailments. While they are the source of discomforts, disability and loss of time for adults they are substantial cause of morbidity among children. Many of these infections run their natural course in children without their specific treatment and without complications. However, in infants and small children or in persons with impaired respiratory track reserves, it increases the morbidity and mortality rates.  The clinical feature includes running nose, cough, sore throat, difficult breathing and ear problem. In most children with these infections have only mild infections, such as cold or cough. However some children may have pneumonia which is major cause of death. In less developed countries, measles and whooping cough are important causes of severe respiratory tract infections. 

Environmental risk factors for respiratory illnesses are well documented. Poor housing quality may result in the spread of molds and allergens throughout the living quarters. The burning of biomass fuel in inefficient stoves or poorly ventilated living space increases the level of inhalation of suspended particulates, while crowding increases the airborne infectious agent from person to person.

Measles and pertussis are diseases that are often complicated by  ARIs.  Lanata and Black (2001) conjecture that “increasing immunization coverage with measles vaccine and with diphtheria-pertussis-tetanus vaccine would be expected to lower the death from these two vaccine preventable causes of acute respiratory infections”.  On the other hand, most episodes of ARI morbidities are not a complication of measles or pertussis, but rather attributable to a myriad of both viral (primarily respiratory syncytial virus, adenovirus, parainfluenza virus and influenza virus) and bacterial (primarily streptococcus, peneumoniae and haemophillus influenza) agents (Lanata and Black, 2001)

Table 1:  Prevalence of ARI Background Characteristics

Table 1 shows the prevalence of ARI by different background characteristics. It may be seen from the tablet the prevalence of ARI is more (7.2 percent) among the child below 1 year compared to age-group 1-5 (5.4 percent). New born infants benefit from maternal antibodies through breast milk. By the age 6-9 months, when complementary foods are recommended to be introduced, passively acquired immunity diminishes greatly. The table also represents the difference in ARI prevalence between rural and urban areas. The prevalence rate is higher among Muslim children (8.1 percent) and among rural children (5.6 percent). The prevalence of ARI varies by immunization coverage. The children who are fully immunized (5.1 percent) are less affected by ARI than those who are partially immunized (5.4), and those who are not immunized are most affected by ARI (6.8 percent). With increasing altitudes the prevalence of ARI is decreasing from 5.5 percent to 4.0 percent.

Table-1.2: Variation in Prevalence of ARI among Children’s Under Age Five by Different Household Environmental Factors

Table 1.2 shows the Variation in prevalence of ARI among children’s under age five by different household environmental factors. Household environmental factors shows the Variation in prevalence of ARI among children’s under age five. Household environmental factors include type of fuel used for cooking, separate room used for kitchen or not, presence of chimney in the house or not, household density and type of toilet facility used. Those household use Bio-mass fuels are more chances to have ARI, (1.8 percent more) than those use Kerosene/LPG/Electricity. In the household where chimney is not present, the prevalence of ARI is more, (5.8 percent) than those household have chimney, (4.2 percent) also those household where the density is above five people per sleeping room the chance of suffering from ARI is more (5.8 percent) as against the households where household density is relatively lower.

Socio-Economic and Environmental Correlates of ARI among Children

Empirical studies of child morbidity have often found that morbidity was more strongly correlated with age of child, education of mother and place of residence.  Residence is multidimensional factor with respect to disease risk. Source of drinking water and sanitation facilities in rural communities are often more rudimentary than those in urban communities, although urban slums areas often lack improved amenities as well. Children in rural areas are more likely to be around animals and their feces than are urban children. Also health care facilities and provides may be less available or accessible in rural areas to treat a sick child (Legrand and Lalou, 1997). Mother’s education is also thought to be associated with hygiene, care seeking and treatment of illness behavior pertaining to early childhood morbidities.

While boys and girls are equally susceptible to common pathogens, gender in equalities may occur with regard to expenditure of money and time to obtain care for sick child. Inequalities may also be found between first born and later born children. Older mothers are generally more experienced in child care, including care during illness. However older mothers may also be less inclined than younger mothers to adopt change in recommendations for illness treatment, preferring to maintain past practices.

Table2 Logistic Regression Analysis to Identify the Risk fFctor of ARI children Under Age Five in India

                                   Note ***      <0.01, ** p<0.05, * P<0.1,

Table 3 shows that percentage of children under five years of age with ARI in two weeks preceding the survey who were taken to health facility and source of treatment according to selected background characteristic. Children are suffered from ARI among those 63 percent are soughting for the treatment of ARI. The treatment seeking is more among the children less than one year age group (66.5 percent) than the children 1-5 years age group (62 percent). Among male children (64.6 percent), mothers age 20-30 years (63.7 percent), mother’s education secondary and above (69.5 percent), belonging from other caste group (67.2 percent), and belonging from higher standard of living (70.9 percent) treatment seeking is more than female children (61.1 percent), mothers age more than 30 years (60.6 percent), mothers have no education (58.5 percent), belonging from SC/ST (59.6 percent) and low standard of living (57 percent). Urban children are soughed more for treatment seeking (72 percent) but among rural children it is 12 percent points less than the urban children. Among working mother treatment seeking is less (60 percent) than those are not working (64.8 percent). Mass media exposure is also a very good indicator to represent treatment seeking. Those who have mass media exposure (64.9 percent), they are 6.3 percent points more soughted for treatment than those have no exposure (58.6 percent). In the first birth order treatment seeking is high than 2 and more birth order of the child.  Among those who sought for treatment more than fifty percent (53.9 percent) had taken the facility from private sources.  About 12 percent, 3 percent and 2 percent had taken the facility from government, traditional and other sources respectively. Only 0.3 percent has taken treatment at NGO.

Table 4: Adjusted Proportion of Sources of Treatment for ARI by Selected Background Characteristics

Table 4 presents the result of adjusted proportion of children who have sought treatment from different facilities for ARI. The table reveals that irrespective of background characteristics higher proportion of children have sought treatment from private facilities compared to government or other facilities. It is seen that irrespective of age of the child significantly higher proportion of children sought treatment from the private facilities than government or others facilities. Sources of treatment for ARI have not changed with the sex of the child. Irrespective of age of the mother more than two third of the children have sought treatment from private facilities. Significantly higher proportion of urban children (75%) compared to rural children (68%) have sought treatment from private facilities. Significantly higher proportion of children from OBC category (75%) has sought treatment from private facilities compared to children from SC/ST (67%) or other (71%) categories. It was expected that higher proportion of working mothers will opt for private facilities for treatment compared to non working mothers. But the result reveals that higher proportion of children of non working mothers have sought treatment (73%) from private facilities compared to children of working mothers (68%). Children whose mother had exposure to mass media a lesser proportion (70%) of them have sought treatment from private facilities compared to children whose mother did not have such exposure (76%). This finding was statistically significant at 1 percent level of significance. Significantly higher proportion of children from higher standard of living have sought treatment from private facilities (78%) compared to children from low (65%) or medium (66%) SLI households.

Table-5: Distribution of the Sick who did not Received Medical Treatment by Age, Sex and Place of Residence

The Table 9 shows distributions of the sick children who did not received medical treatment by age, sex and place of residence. Sex of the child is an important factor to describe distributions of the sick children who did not received medical treatment. In case of ARI /fever about one-third (30.8 percent) female child did not received any treatment. In comparison to female child low

percentage male children (27.6 percent) are not received any medical treatment. Residence is more prominent factor to describe that where less number of children are taken treatment. Numbers of rural children were not given any medical treatment (31.4 percent and 45.8 percent respectively) than the urban areas (22.2 percent and 36.9 percent respectively). The overall figure shows that more than one-fourth (29.1 percent) of the children who suffered by ARI/fever did not taken any kind of medical treatment. More than two-fifth (43.5 percent) children, which is 14.4 percent points more than ARI are taken any treatment. The children below one year age group suffered by ARI/fever, among them 27.2 percent did not received treatment and this percentage is more for the children in the age group 1-5 years (29.6 percent).

Summary and Recommendations

This study reveals that the age of child is a significant factor in the prevalence of ARI among children under age five. The analysis shows that children whose mother attended secondary or above education were less likely to suffer from ARI than those children whose mother got no education. Type of housing appeared to be one of the important risk factor for the disease. Children living in houses built with tin or earthen material mostly suffers from ARI compared with children lived in houses built with brick/cement. Children lived in puccha houses enjoyed better socio-economic status which in turn ensures better health. Child who belongs to low SLI families suffers more from ARI and vice-versa establishing the hypothesis to be true. Exposure to mass-media always had a prominent positive impact and better understanding towards the child health care, which is supported by the study that children whose mothers having no mass-media exposure are more susceptible to the disease. Similarly children belonging to rural area are more prone to ARI. Results of this study indicate that prevalence of ARI, is slightly higher among male children. 

The hypothesis which was made that the prevalence of ARI would be higher in high altitude areas has been rejected in this analysis, as it may be seen that PSU those were situated at 1000 meters above from the sea level, none of children from such PSUs have suffered from ARI in last 2 weeks preceding the survey. It is important to mention that the sample size was very less in higher altitude PSUs. Immunization has always remained as one of the major medication to control the spread of disease. Childhood immunization played an important role as it is seen that the prevalence of ARI were higher among children who have not received any vaccination. Sanitation in and around house is determined by number of people living in the house, ventilation in the kitchen, use of clean (portable) water, disposal of wastage, personal hygiene and kitchen hygiene. Among these household environmental variables crowding, type of fuel used for cooking and presence of chimney in kitchen have shown strong correlation with prevalence of ARI. A higher proportion of children whose household have used bio-mass fuel for cooking have suffered more from ARI compared to others. This is because bio-mass fuel creates more smoke compared to other fuels.  Presence of chimney in kitchen is an important indicator in determining the prevalence of ARI as Presence of chimney in kitchen indicates better ventilation. Results depict that children of those household which lacks chimney contributes more in ARI prevalence. Also the houses having higher household density (five and above) shows high prevalence of ARI among children’s under age of five years than those having low household density (2, 3-4).  Therefore it clearly establishes the hypothesis “prevalence of ARI increases with poor housing and Sanitation condition”.

 Considering treatment seeking behavior among the children it was observed that 29 percent of ARI treatments were not amenable for any type of medical treatment. About 30 percent of child between ages one to five were not provided any medical care for the treatment of ARI as these figure are low for child less than one year (27 percent). Again more are the cases of not seeking any medical treatment for ARI remains in rural areas and about 31 percent of female child were not given any medical treatment than their male counterparts (27 percent) revels the existence of gender biases in treatment seeking behavior for the disease.

In view of the treatment seeking behavior among the children’s those who sought treatment for ARI, more than fifty percent (53.9 percent) had taken the facility from private sources, 12.2 percent, 3.3 percent and 2.3 percent had taken the facility from government, traditional and other sources respectively. Whereas only .3 percent had taken treatment from NGO. Most significant feature observed in this study is, about 56 percent of children less than one year of age suffering from ARI were provided private health care facilities. 55 percent of male child were provided private treatment whereas only 52 percent of female child were treated at private health care provider. Younger mothers are more intended to seek private treatment than the older ones. In terms of differentials children of mothers having higher education, exposure to mass-media, belonging to upper caste, mostly Hindus and residing in urban areas are more intended to take private treatment in the case of ARI.

Conceiving thus it can be said that Acute Respiratory Infections is the most common symptom of illness among young children in India, and it is associated with a wide range of causes. Thus, differential diagnosis by health care practitioners of a child pertaining with the diseases requires knowledge of proper conducive settings in which they grow and also to ensure better environmental conditions. Therefore any interventions related to child development should specially target the “household environmental factors” that mitigate prevalence of the disease among them. Generally, it is observed that deaths due to ARI occur because either the child has not received any medical treatment or received poor treatment. Relatively cheap and effective antibodies are available for treatment of ARI. Many lives can be averted if therapy is provided timely at an appropriate place.

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