Received Date: July 31, 2012; Accepted Date: October 26, 2012; Published Date: October 28, 2012
Citation: Goel K, Ahmad S, Agarwal G, Goel P, Vijay Kumar (2012) A Cross Sectional Study on Prevalence of Acute Respiratory Infections (ARI) in Under- Five Children of Meerut District, India. J Community Med Health Educ 2:176. doi:10.4172/2161-0711.1000176
Copyright: © 2012 Goel K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Acute respiratory infection (ARI) is a leading cause of morbidity and mortality in under-five children worldwide. On an average, children below 5 years of age suffer about 5 episodes of ARI per child per year, thus accounting for about 238 million attacks and about 13 million deaths every year in the world. Identification of modifiable risk factors of ARI may help in reducing the burden of disease.
Objective: To study the social demographic factors and prevalence of ARI in under five children living in urban and rural area of Meerut district.
Materials and methods: A cross sectional study covering 450 under-five children living in urban and rural area of Meerut district from October 2011 to March 2012.
Results: Prevalence of ARI was found to be 52%. It was higher in children with lower socioeconomic status (35.89%), illiterate mother (49.14%), overcrowded conditions (70.94%), inadequate ventilation (74.35%), and use of smoky chullah (56.83%), malnutrition (26.49) and parental smoking (78.20%).
Conclusion: The present study found that low socioeconomic status, maternal illiteracy, poor nutritional status, overcrowding, indoor air pollution and parental smoking behavior were the significant social and demographic risk factors responsible for ARI in under-five children. These observations emphasize the need for research aimed at health system to determine the most appropriate approaches to control acute respiratory infection and thus could be utilized to strengthen the ARI control programme.
Acute respiratory infections; Under-five children; Mother illiteracy; Indoor air pollution; Parental smoking
Acute respiratory infection (ARI) in under-five children is one of the main public health problems in India. It is the major cause of morbidity and mortality in infants and young children below age 5. Every year ARI in young children is responsible for an estimated 3.9 million deaths worldwide. ARI contributes to 15-30% of all under-five deaths in India and most of these deaths are preventable . ARI is an important cause of morbidity in the children. On an average, children below 5 years of age suffer about 5 episodes of ARI per child per year, thus accounting for about 238 million attacks. Hospital records from states with high infant mortality rate shows that up to 13% of inpatient deaths in pediatric wards are due to ARI. The proportion of death due to ARI in the community is much higher as many children die at home. In India in 2008, about 27.4 million cases of ARI were reported which gives an incidence rate of about 2394 cases per lakh population .
Many risk factors for respiratory tract infections have been identified which include not only the climatic conditions but also the poverty, poor nutrition, poor housing conditions, indoor air pollution such as parental smoking, absence of ventilation, overcrowding, industrialization, social cultural values, overuse and misuse of antibiotics, lack of basic health services and lack of awareness.
There are multiple social and environmental factors associated with ARI morbidity and mortality in childhood. These include comorbid illnesses especially HIV, malnutrition, prematurity or measles, environmental determinants particularly passive smoke exposure, overcrowding or poor living conditions and social factors principally poverty and poor access to both preventative (including immunization) and curative health services.
Hence the present study was conducted to determine the prevalence and important socio-demographic factors associated with ARI.
A cross sectional study was carried out among 450 under-five children living in urban and rural area of Meerut district during October 2011 to March 2012.
Clearance from the Subharti ethical committee was first obtained. Out of 450 studied children, 225 children were selected from urban area, Multan Nagar and 225 children were selected from rural area, Khajuri under the field practice area of Department of Community Medicine, Subharti Medical College, Meerut. Purposive sampling was used. A pre-designed and pre-tested questionnaire was used for data collection. The questionnaire included information regarding socio-demographic profile, housing conditions, type of cooking fuel used, anthropometric and clinical examination. House to house survey was done for data collection. History of episodes of ARI during last one year was enquired for calculating the prevalence of ARI among children under-five. Social classification is done on the basis of Modified Prasad’s classification revised according to inflation rate in year 2007-2008. Data was entered into SPSS package (version 16.0) and was analyzed by using chi-square test and the results were expressed as proportions.
Out of 450 children, the sex wise distribution was almost equal with 52% males and 48% females. In the study, about 47.55% (214) were in between 1-4 yrs, 39.33% (177) were below age of 1 yr and 13.11% (59) were in between 4-5 yrs of age. No major difference was found in rural and urban area. Males were more in urban area (58.22%) and females were more in rural area (54.22%). Majority were Hindus (76%) followed by Muslims (21%). About one-fifth (19%) of children belonged to upper social class (I, II) and remaining (79%) were in low social class (III, IV, V). 42% of children were living in proper houses, it was more in urban area (61%) as compared to rural area (23%). Overcrowding was present in more than half of the houses (56%), it was more in rural area (71%). Cross ventilation was present in 42% of houses, it was more in urban (61%) as compare to rural area (23%). 34% children were from households using smokeless fuel which is more in urban area (58%) as compare to rural area (33%). 34% father and 52% mother of children were illiterate (more in rural area 46%, 73% respectively). According to occupational status of parents, 46% fathers were laborers, 71% mothers were housewives, 16% were laborers. History of parental smoking was present in 66% of houses, it was more in rural area (74%). About 29% were malnourished children (13% had grade-I, 11% had grade-II and remaining had grade-III and IV), it was more in rural area (46%). According to symptoms, about 71% of children having cough, 60% nasal discharge, 30% fever, 16% fast breathing and 2% stopped feeding.
Prevalence of ARI
The overall prevalence of ARI was 52%. A total of 234 ARI cases were found during the study. The mean number of episodes of ARI was 2.25 per child per year. According to sex-wise 53.84% were males and 46.15% were females. More ARI cases were seen in 1-4 years of age group (46.15%) and in this age group 45.24% were males and 47.22% were females (Table 1). According to social class, prevalence of ARI was higher in low social class (in class III - 20.94%, class IV -32.9%, and class V- 35.89% respectively) (Table 2). This difference was statistically significant (x2=13.72, p<0.001). In social class IV and class V, prevalence of ARI was more in rural area (34.43%, 37.77%) as compare to urban area (30.12%, 32.53%). This difference was statistically significant (x2=15.7, p<0.05) (Table 2).
|Age group (yrs)||Male||Female||Total|
Table 1: Distribution of ARI cases according to age and sex wise.
|Urban (%)||Rural (%)||Total (%)|
|ARI Present||83 (36.89)||151 (67.11)||234 (52.00)|
|ARI Absent||142 (63.11)||74 (32.89)||216 (48.00)|
|Distribution of ARI cases according to gender|
|Male||56 (67.46)||70 (46.36)||126 (53.84)|
|Female||27 (32.53)||81 (53.64)||108 (46.16)|
|Distribution of ARI cases according to age wise|
|0-1 Yr||25 (30.12)||73 (48.34)||98 (41.88)|
|1-4 Yrs||42 (50.60)||66 (43.70)||108 (46.15)|
|4-5 Yrs||16 (19.27)||12 (07.94)||28 (11.96)|
|Distribution of ARI according to Social class|
|Social class I||06 (07.22)||01 (00.66)||07 (02.99)|
|Social class II||09 (10.84)||08 (05.29)||17 (07.26)|
|Social class III||16 (19.27)||33 (21.85)||49 (20.94)|
|Social class IV||25 (30.12)||52 (34.43)||77 (32.90)|
|Social class V||27 (32.53)||57 (37.74)||84 (35.89)|
|Mother’s education of ARI Children|
|Illiterate||36 (43.37)||79 (52.31)||115 (49.14)|
|Primary||21 (25.30)||31 (20.52)||52 (34.43)|
|High school||12 (14.45)||22 (14.56)||34 (14.52)|
|Intermediate||08 (09.63)||11 (07.28)||19 (08.11)|
|Above Intermediate||06 (07.22)||08 (05.29)||14 (05.98)|
|Laborer||19 (22.89)||37 (24.50)||56 (23.93)|
|Pvt. Service||26 (31.32)||11 (07.28)||37 (15.81)|
|Agricultural||00 (00.00)||83 (54.96)||83 (35.47)|
|Business||32 (38.55)||16 (10.59)||48 (20.51)|
|Govt. Service||06 (07.22)||04 (02.64)||10 (04.27)|
|History of Parental smoking|
|Yes||52 ( 62.65)||131 (86.75)||183 (78.20)|
|No||31 (37.34)||20 (13.24)||51 (21.79)|
|Yes||47 (56.62)||119 (78.80)||166 (70.94)|
|No||36 (43.37)||32 (21.19)||68 (29.05)|
|Inadequate ventilation||45 (54.21)||129 (85.43)||174 (74.35)|
|Adequate ventilation||38 (45.78)||22 (14.56)||60 (25.64)|
|Use of domestic fuel|
|Smoky Chullah||19 (22.89)||114 (75.49)||133 (56.83)|
|Smokeless Chullah||41 (49.39)||30 (19.86)||71 (30.34)|
|Others||23 (27.71)||07 (04.63)||30 (12.82)|
|Distribution of ARI cases according to Nutritional Status|
|Normal||15 (18.07)||53 (35.09)||68 (29.05)|
|Grade I||23 (27.71)||39 (25.82)||62 (26.49)|
|Grade II||19 (22.89)||26 (17.21)||45 (19.23)|
|Grade III||15 (18.07)||21 (13.90)||36 (15.38)|
|Grade IV||11 (13.25)||12 ( 07.94)||23 (09.82)|
Table 2: Social demographic factors and ARI cases in under five children of Meerut.
Prevalence of ARI was highest in children of illiterate (49.14%) and primary (34.43%) mothers. According to occupation of father, prevalence of ARI was highest in children of fathers who were engaged in agriculture (35.47%) and laborers (23.93%). Prevalence of ARI was more in those children having history of parental smoking (78.20%) as compared history of non-parental smoking (21.79%). Overcrowding and inadequate ventilation has a direct relationship with prevalence of ARI. ARI was higher in children (70.94%) who were living in overcrowded houses as compare to no overcrowding (29.05%) and inadequate ventilation was 74.35%. Prevalence of ARI was higher in children of mothers who were using smoky chullhas (56.83%) as compared to using smokeless chullhas (30.34%). Nutrition status of children had also a direct bearing on children’s susceptibility to ARI. It was more in Grade-I (26.49%), Grade-II (19.23%), Grade-III (15.38%) and Grade-IV (09.82 %) respectively.
Overcrowding has a direct relationship with prevalence of ARI; it was higher (70.94%) in children who were living in overcrowded houses as compare to no overcrowding (29.05%). This difference was statistically highly significant (x2=13.28, p<0.001). Prevalence of ARI was more in children living in houses with inadequate ventilation (74.35%) as compared to houses with adequate ventilation (25.64%). This difference was statistically significant (x2=12.23, p<0.001). Prevalence of ARI was higher in children of mothers who were using smoky chullhas (56.83%) as compared to using smokeless chullhas (30.34%). This difference was statistically significant (x2=3.91, p<0.001). According to exposure to type of fuel and types of ARI, ARI cases were more seen in rural area (75.49%) as compared to urban area (22.89%) where smoky fuel was used but difference was not statistically significant (p>0.05). Nutritional status of child has direct bearing on children’s susceptibility to ARI. Prevalence of ARI amongst children who had no malnutrition was lowest (16.0%), while it was more in Grade-I to IV malnutrition. This difference was statistically significant (x2=37.83, p<0.001) (Table 2).
In the study overall prevalence of ARI was found to be 52%. Our findings are similar to the findings of a study done by Rahman and Rahman  in Bangladesh where prevalence of ARI was found to be 58.7%. Our findings are in contrast to the findings of the studies conducted by Prajapati et al.  in Gujrat where the prevalence of ARI was found to be 22% and Gupta et al.  where the prevalence of ARI was 4.5%. In present study 53.84% of ARI cases were males and 46.15% were females. This study showed that ARI was more prevalent among male children and similar study conducted in London, United Kingdom by Leeder et al.  had similar results showing male sex was more prone as compared to female.
According to social class, prevalence of ARI was higher in low social class. The present study found a significant association between ARI and social class (p<0.001). Various studies like by Gupta et al. , Deb et al.  and Mitra  found similar association.
According to area, Prevalence of ARI was lower in urban area (36.89%) as compared to rural area (67.11%). Similar observations were seen in study done by Deb .
The present study found no association between ARI and literacy status of mothers (p>0.05). Similar findings observed in study done by Mitra .
Prevalence of ARI was more in those children having history of parental smoking (78.20%). Similar findings were observed in a study by Rahman and Rahman  in Bangladesh. Studies done on exposure of cigarette smoke in Australia and risk of parental smoking in UK have increased risk of hospitalization with ARI [9,10].
Prevalence of ARI was higher in children of mothers who were using smoky chullhas (56.83%). Similar study in rural areas of Australia also showed increase risk of developing LRTI among those using wood fuel .
An another study conducted by Pore et al.  revealed that significant association was found that between ARI and nutritional status, immunization status, weaning, mothers’ literacy status in pediatric ward of S.C.S.M. General Hospital, Solapur. A study conducted by Gupta et al.  suggested that the factor analysis, crowding, economic status, and sanitary conditions are important associates of prevalence of ARI. The incidence of pneumonia was found to be the highest in infant group. Lower socio-economic status and malnourished had the greater risk of ARI episodes .
In a study done by Mitra  showed that low socio-economic class, low birth weight, under-nutrition of the child, inadequate immunization, children not exclusively breastfed and indoor smoke pollution were significantly associated with increasing number of ARI episodes. A study conducted by Peat et al.  suggested that between 500-2500 excess hospitalizations and between 1000 to 5000 excess diagnoses per 100,000 young children as result from respiratory infections can be directly attributed to parental smoking.
A study by Singh and Nayar  discussed that the incidence of ARI was found to be closely associated with nutritional status of the child, socio-economic status of the family, maternal literacy status and family size. Environmental factors like type of house, ventilation and fuel used for cooking were found to influence the incidence of ARI.
Chhabra et al.  reported that Lower respiratory infection was more affected by adverse nutritional status than upper respiratory infection. ARI incidence was also significantly lower among children living in well-ventilated homes (1.79 episodes/child/year) than those living in poorly ventilated homes (2.87 episodes/child/year).
The present study found that low socioeconomic status, maternal illiteracy, poor nutritional status, overcrowding, indoor air pollution and parental smoking behaviour were the significant social and demographic risk factors responsible for ARI in under-five children. Based on the findings, occurrence of ARI could be reduced by improved living, environmental conditions and nutrition of children. Raising female literacy level and awareness regarding indoor pollution will go a long way in prevention of morbidity amongst children in general and ARI. These observations emphasize the need for research aimed at health system to determine the most appropriate approaches to control acute respiratory infection and thus could be utilized to strengthen the ARI control programme.
Authors are thankful to Mr. Shiv Kumar, Mr. Anil Kumar and Mr. Praveen Kumar (data entry operators), Zulfikar Ali (field volunteer) for their help and to the parents of children who shared their valuable experiences, spent precious time and for their participation.
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