A STUDY ON THE HEALTH STATUS OF ADOLESCENT

GIRLS RESIDING IN SOCIAL WELFARE HOSTELS OF

NELLORE CITY, A.P.

Dissertation submitted to
Dr. NTR UNIVERSITY OF HEALTH SCIENCES
VIJAYAWADA (A.P.)

In partial fulfillment of the requirement for the

DOCTOR OF MEDICINE
IN
COMMUNITY MEDICINE

To be held in April –May, 2010

By

Dr. K. MUNI SUSMITHA M.B;B.S.,

DEPARTMENT OF COMMUNITY MEDICINE

NARAYANA MEDICAL COLLEGE
NELLORE-524 002
ANDHRA PRADESH
INDIA

2010
 CERTIFICATE

THIS IS TO CERTIFY THAT THIS DISSERTATION TITLED

“A STUDY ON THE HEALTH STATUS OF ADOLESCENT
GIRLS RESIDING IN SOCIAL WELFARE HOSTELS OF
NELLORE CITY, A.P.”IS THE ORIGINAL INVESTIGATIVE
WORK DONE BY Dr. K. MUNISUSMITHA, M.B.B.S., UNDER MY
SUPERVISION AND GUIDANCE.

DR.N.ANANTHAIAH CHETTY, M.D.,

PROFESSOR & H.O.D,
DEPARMENT OF COMMUNITY
MEDICINE,
NARAYANA MEDICAL COLLEGE,
PLACE: NELLORE NELLORE. (A.P.)
DATE: 24 .11.2009

PROFESSOR OF COMMUNITY
MEDICINE,
NARAYANA MEDICAL COLLEGE,
NELLORE, (A.P.)
 Dr. N.T.R. UNIVERSITY OF HEALTH SCIENCES
VIJAYAWADA (A.P.)

DECLARATION BY THE CANDIDATE

I, Dr. K. Muni Susmitha, hereby declare that, this dissertation titled

“A Study On The Health Status Of Adolescent Girls Residing In Social

Welfare Hostels Of Nellore City, A.P.” has been prepared by me is being

submitted to the Dr. N. T. R. University of Health Sciences, Vijayawada,

Andhra Pradesh in partial fulfillment of the regulations for the award of

degree of Doctor of Medicine (Community Medicine), examination to be

held in April 2010.

Date : 24.11.2009

Place: Nellore (Dr. K. Muni Susmitha)

3
 I am greatly indebted to my respected Professor and

Head of the department, Dr.N.Ananthaiah Chetty for his

valuable guidance in shaping up this dissertation work.

I thank Dr.V.VenugopalReddy, Professor, department

of community medicine for his invaluable suggestions. I also

thank immensely Dr. G. Sreenath, former Professor and

Head of the department for his invaluable guidance.

I sincerely thank Dr.Abhay B.Mane and

Dr.R.Rajkumar and Dr.C.Kumar Associate Professors of

the department for their valuable help and guidance.

I express my deep sense of gratitude to Dr.E.Venkat

Rao and Dr. C.Jyothi Assistant professors of the

department for helping me constantly throughout the work.

I am extremely thankful to my colleague post

graduates and other staff members of the department for

their moral support and help whenever sought.

I sincerely thank the Hostel Welfare Officers of social

welfare hostels, Nellore, for the kind help extended. I also

4
thank the other members of social welfare hostels involved

in the study for the help extended.

Last but not the least; I am extremely thankful to the

study subjects enrolled in the study for their participation

and cooperation in successfully carrying out this study.

Dr. K. MUNISUSMITHA

5
 LIST OF ABBREVIATIONS USED

ARI – Acute Respiratory Infections

BMI – Body Mass Index
Ht – Height
ICMR – Indian Council of Medical Research
ICRW - International Center for Research on Women
NCHS – National Centre for Health Statistics
NFHS – National Family and Health Survey
NHANES - National Health and Nutrition Examination Survey
NNMB – National Nutrition Monitoring Bureau
RCH – Reproductive and Child Health
STI/RTI – Sexual Transmitted / Reproductive Tract Infections
SC and ST – Scheduled Caste and Scheduled Tribes
UTI – Urinary Tract Infections
WHO – World Health Organization
Wt – Weight

6
 CONTENTS

S.NO TITLE PAGE NO.

1) INTRODUCTION 01- 05

2) AIMS AND OBJECTIVES 06

3) REVIEW OF LITERATURE 07- 40

4) MATERIALS AND METHODS 41 - 47

5) RESULTS 48 - 73

6) DISCUSSION 74 - 85

7) SUMMARY & CONCLUSIONS 86- 87

8) RECOMMENDATIONS 88 -89

9) LIMITATIONS 90

10) BIBLIOGRAPHY 91 – 100

11) ANNEXURES

7
INTRODUCTION

8
 INTRODUCTION

WHO defines adolescence as the segment of life between the ages of

10-19 years. Adolescence is a transition phase through which a child

becomes an adult. It is characterized by rapid growth and development;

physiologically, psychologically and socially.1

There are 1-2 billion adolescents in the world, 85% of them live in

developing countries.2 The adolescent population constitutes about 18-25%

of the total population of the South East Asia Region.1

About one-fifth of India’s population is in the adolescent age group of

10–19 years. Adolescents constitute a sizeable proportion of the Indian

mothers. However, despite adolescents being a huge segment of the

population, policies and programs in India have focused very little on the

adolescent group.

Adolescents constitute perhaps the healthiest group in the population,

having the lowest mortality and morbidity compared with other population

age groups. Adolescents are an “in between group”, with some nutrition

problem, some common with children and some with adults. In addition,

there are adolescent-specific issues that call for specific strategies and

interventions.1 However, the period of adolescence, beginning with the onset

of puberty, is a crucial to healthy transition into adulthood. Most adolescents

9
go through adolescence with little or no knowledge of the body’s impending

physical and physiological changes, health issues and problems. Early

marriages, high fertility rates, high rates of teenage pregnancy, high risk of

STI/RTI, and poor nutritional status are the main health problems among the

adolescent population in India.3

The newer focus on RCH also has been invigorated by the continuing

realization of the importance of women’s health; it is now widely accepted

that if the health of women is to be improved, the health of adolescents must

be given high priority in Indian policy and programme development and

implementation.3

Girls are deprived of nutrition, access to health care, and opportunities

for education and employment. They are taken out of schools when they

reach menarche. From the very beginning of life, girls are groomed to

accommodate the male-dominated, patriarchal society. Girl children grow

into adulthood without being able to experience the important period of

adolescence. Nearly 46.6 % of adolescent girls are illiterate when compared

with males (25.5 %).3

Anaemia is a widely prevalent health problem among adolescent girls.

Both the 1992 ICMR study on Iron and Folic Acid supplementation and

UNICEF have reported low mean hemoglobin levels and low nutritional

intake of proteins, calories, and macro/micronutrients among adolescent

10
girls and pregnant mothers. Poor physical growth and stunting are the

primary outcomes of poor nutrition. The 1998–99 NFHS-2 reported that the

prevalence of anaemia was highest (56 %) among adolescents (ages 15–19)

compared with other group of women of reproductive age.3

Adolescent health is the domain of the Ministry of Health and Family

Welfare at central level and the Department of Health and Family Welfare at

state level. The Ministry of Women and Child Development is significantly

involved in the issues of nutrition and development of children, particularly

girl children. The major thrust to adolescent health, however, was given in

the National Population Policy 2000. The National Youth Policy, 1986 (New

Draft National Youth Policy, 2000) placed adolescent health as a subsection

under the health sector.3

In Andhra Pradesh, this segment constitutes approximately 5.03% of

the population. The importance of this target group lies in the fact that they

are going to be the mothers of tomorrow – whose well being is critically

important for improving the nutritional, health and educational status of

women in the State. Various base line surveys also revealed that the health,

nutritional and educational status of adolescent girls are at sub-optimal

level.4

The scheduled castes and scheduled tribes have been identified as two

most disadvantaged groups of Indian society needing special attention.5

11
 As per 2001 census, Scheduled Castes constitute about 16.2% and

Scheduled Tribes about 8.1% of the Indian population, and in Andhra

Pradesh they constitute about 16.2% and 6.6 % of population.6

The school age children from poor Scheduled Castes families are not

being sent to school because of the tendency of some parents to utilize the

services of their children at their tender age, in order to augment their family

income. A provision for educational opportunities forms a very important

part of the programme for the welfare of the SCs and the STs.

Empowerment of the Adolescent Girl is necessary to help her cope

with the changes and promote awareness of health, hygiene and nutrition so

as to break the intergenerational life cycle of nutritional and gender

disadvantage and provide an enabling and supporting environment for self

development.4

The main mission of the social welfare department is educational,

socio-economic development, welfare and protection of scheduled castes.

This department, with respect to the socioeconomic status of SC population

and socio academic profile of the scheduled caste children, has been

maintaining hostels as a pro-educational measure. These hostels serve as

homes away from homes at places where schooling facilities are available.

The girls stay more than 8 years in these hostels. Health care of the

girls in the hostels is of utmost importance because the children in the school

12
age (5-15years) are in a period of growth and development when optimum

nutritional and health care is essential. Good health and nutrition are

necessary for proper learning at school. Inculcation of healthful habits

among these adolescents will have permanent benefit in their lives and also

the ideas and practices will influence their families and communities. As

these girls have come out of their environment and are living in groups, they

face special risks and need extra care for the maintenance and improvement

of their health and nutrition.

The data regarding the nutritional status, morbidity status and sanitary

conditions of the social welfare hostels for the scheduled castes are sparse,

despite the usefulness of such information in the management of hostels and

upliftment of these groups.7

In this context, the present study was taken up among adolescent girls

residing in the social welfare hostels for scheduled castes in Nellore city.

This study focuses on health and nutritional status of adolescent girls and the

environmental conditions in the hostels.

13
 AIMS
AND
OBJECTIVES

14
 AIM

To study the health status of adolescent girls residing in social welfare

hostels of Nellore city, A.P.

OBJECTIVES

1. To assess the Nutritional status of the adolescent girls residing in the

hostel.

2. To study the Morbidity pattern among the adolescent girls in the

social welfare hostels for scheduled castes.

3. To describe the menstrual health problems of the adolescent girls in

the social welfare hostels.

4. To describe the environmental conditions of the hostels.

15
 REVIEW OF
LITERATURE

16
 REVIEW OF LITERATURE

Adolescence definition

No longer children, not yet adults. Adolescence is a period of rapid

development when young people acquire new capacities and are faced with

many new situations.8

The World Health Organization defines adolescents as young people

aged 10-19 years.9

As they grow they feel a sense of independence, but depend on adults

for their material needs. And as they change, so do their needs change with

them.

Phases in adolescence

1. Early adolescence (10-13yrs): It is characterised by a spurt of

growth, and the beginning of sexual maturation. Young people start to

think abstractly.

2. Mid-adolescence(14-15yrs):The main physical changes are

completed, while the individual develops a stronger sense of identity,

and relates more strongly to his or her peer group, although families

usually remain important. Thinking becomes more reflective.

17
 3. Late adolescence (16-19yrs): The body fills out and takes its adult

form, while the individual now has a distinct identity and have more

settled ideas and opinions.

Special characteristics

Over 80% of adolescent growth (attained weight and height) is

completed in early adolescence (10-15 years), with a marked deceleration in

weight and height velocity in the post-pubertal phase. This adolescent

growth spurt is also associated with cognitive, emotional and hormonal

changes.1

This phase of life cycle is marked by special characteristics which include

1. Rapid physical growth and development.

2. Physical, social and psychological maturity.

3. Sexual maturity and onset of sexual activity.

4. Beginning of menstruation in girls and onset of reproduction

cycle.

5. Experimentation.

6. Development of adult mental processes and adult identity.

7. Transition. 10

Numerical facts

18
 There are about 1.2 billion adolescents, a fifth of the world’s

population and their number is increasing. Four out of five live in

developing countries.9

Adolescents constitute about 23% of population in India. In India,

girls constitute 5.1% of adolescents in 10 - 14 years age group and 4.8% in

15 – 19 years age group.1

Factors affecting health status of adolescents

The lives of millions of adolescents are marred by poverty,

inadequate education and work opportunities, exploitation, war, civil unrest

and ethnic and gender discrimination. Rapid urbanization,

telecommunication, travel and migration bring both new possibilities and

new risks to young people. These conditions may directly jeopardize health.8

Health problems of adolescents are interrelated. Many of the factors

that underlie unhealthy development in adolescents are decreasing influence

of family and culture, earlier puberty and late marriage - all these extend the

risks of unprotected sexual activity in unmarried adolescents in many parts

of the world. In some countries, early marriage and childbearing lead to high

maternal and infant mortality rates. In others, sexually transmitted diseases,

including HIV/AIDs, pose enormous health risks to adolescents.8

Potentially harmful substances - tobacco, alcohol and other drugs - are

now more readily available to adolescents and threaten their health in both

19
the short and long term. Violence inflicted by and on young people is a

growing phenomenon. Young men frequently take part in acts of violence,

including wars. Suicide attempts appear to be on the increase among the

young.8

Importance of Adolescent Health

Adolescent girl's health covers morbidity, mortality, nutritional status

and reproductive health and linked to these are environmental degradations,

violence and occupational hazards, all of which have implications for

adolescent girl health.3

Adolescent girl’s health plays an important role in determining the

health of future population, because adolescent girl’s health has an

intergenerational effect. The cumulative impact of the low health situation of

girls is reflected in the high MMR, the incidence of low birth weight babies,

high perinatal mortality and foetal wastage and consequent high fertility

rates.

A transitional period between childhood and adulthood, adolescence

provides an opportunity to prepare for a healthy productive and reproductive

life, and also to prevent the onset of nutrition related chronic diseases in

adult life, while addressing adolescence-specific nutrition issues and

possibly also correcting some nutritional problems originating in the past.11

20
 Nutrition influences growth and development throughout infancy,

childhood and adolescence; it is, however, during the period of adolescence

that nutrient needs are the greatest.11

Nutritional and health needs of the adolescents are more because of

more requirements for growth spurt and increase in physical activity. They

need more of all nutrients particularly calcium, iron and iodine. The need for

more of iron in adolescents is due to growth spurt and the onset of

menstruation. Inadequate iron stored during adolescence and before

conception is a major cause of iron deficiency anaemia during pregnancy,

which aggravates the risk of pregnancy.12

Poor nutrition starts before birth, and generally continues into

adolescence and adult life and can span generations. Chronically

malnourished girls are more likely to remain undernourished during

adolescence and adulthood, and when pregnant, are more likely to deliver

low birth-weight babies.1

Figure showing Nutrition throughout the life cycle.

21
 In order to break the intergenerational cycle of malnutrition, a special

focus for overcoming adolescent malnutrition is needed.1

Health Status of Adolescents

World

For a number of years, the health of adolescents has not been a major

concern and research has consequently been limited, as they are less

22
susceptible to disease and suffer from fewer life-threatening conditions than

children and elderly people. Indeed, adolescence is generally described as a

period of relatively good health with low prevalence of infection and chronic

disease. Mortality and morbidity trends among adolescents are quite similar

in developing and developed countries. It is noteworthy that health services

in developing countries focus on preschool-age children and pregnant

women, with the consequence that health needs of adolescents may not be

adequately met.11

A general profile of adolescent girl’s nutritional status was sketched in

the South-East Asia Region: “They are undernourished, indicating a chronic

energy deficiency. Most often, the BMI of adolescent girls of 13years and

above is below 18.5. The girls are usually physically stunted, a manifestation

of chronic protein energy malnutrition. Iron deficiency anaemia is the most

glaring nutritional deficiency, with not less than 25-40% of adolescent girls

as victims of moderate and sometimes severe anaemia. In all countries of the

region, at least 40-50% of adolescent pregnant girls are anaemic”.

Under nutrition was highly prevalent in three of the 11 studies of

ICRW: 53% in India, 36% in Nepal.11

India

The health of adolescent girl is intricately related to the socio-

economic status of the households to which they belong and their age and

23
kinship status within the households. India has traditionally been a male

dominated society; so there is a strong son preference in most parts of India,

and girls tend to be discriminated by their families. It is not enough,

therefore, to highlight adolescence in general; a larger focus of the girl child

also must be addressed. Demographic trends indicate deep-rooted gender

discrimination which begins with female feticide and prenatal sex

determination.3

Given the predominantly patriarchal setup, girls get a lesser share in

the household distribution of health, goods and services compared to men

and boys. There is data to show that in a situation of extreme food and

scarcity, the adverse effect on the nutritional status is greater on girls than on

boys. Girls in the 13 to 16 years of age group consume less food than boys.

However, in the intra-household distribution of labour, adolescent girls get

the major share of economic, procreative and family responsibilities. Due to

the competing demands on their time and energy as well as their

socialization, girls tend to neglect their health. The lesser access to food

coupled with neglect invariably leads to a poor nutritional status and a state

of ill health for most of the adolescent girls' health.13

As malnutrition among the child population in the country is widely

prevalent, it follows that a moderate to severe degree of malnutrition would

persist among girl child too. As a consequence, the malnutrition persists

24
throughout adolescence and in pregnancy. As a result, the growth and

development of unborn child is affected, giving rise to low birth weight.

About 30 % of the total births in the country constitute low birth weight and

this in turn leads to high infant and child mortality and morbidity. According

to the NNMB data (National Nutrition Monitoring Bureau), a very high

proportion of girls are at obstetric risk as they enter the 14th -15th year of life

with a height less than 145 cm and weight less than 38 Kg.13 However, not

much attention has been paid to adolescents by nutrition-related programmes

in developing countries.1

In order to break the intergenerational transfer of anaemia and cycle

of malnutrition, anaemia control will find a high place in the action plan for

the Adolescent Girls year.1 Women Development & Child Welfare

Department declared the year 2003 as the “Year of the Adolescent Girl.”4

The collaborative study done in Hyderabad, New Delhi, Calcutta and

Madras showed that amongst girls between 6-14 years of age, the prevalence

of anaemia was 63.8%, 65.7%, and 98.7% respectively. A study in rural area

showed that 65.5% parents of adolescent girls never spoke about the

physical changes during puberty, like menarche, with their daughters.13

Special problems of adolescent girls

25
 Unfortunately, the special needs of adolescents are rarely addressed

by the educational, health, and family welfare programs in India. The

commitment of the national government to the reproductive health approach

forged at the International Conference on Population and Development

(ICPD) in 1994 has reshaped the family welfare program into a broad-based

Reproductive and Child Health (RCH) Services Program in India.

Policymakers and planners have now realized that the adolescent population

group has specific health and developmental needs. There is a growing

understanding that adolescence is a bridge between childhood and

adulthood.3

The 1998–99 National Family Health Survey-2 (NFHS-2) reported

that among young female adolescents (ages 10–14 years), 67 % attended

school. The corresponding figure for male adolescents was 80.2 %. Location

had a significant influence on the schooling of females. In rural areas, only

32.7% of female adolescents (ages 15–17) attended school compared with

60.5% of female adolescents in urban areas. More than one-quarter of girls’

lack of education was ascribed to their responsibilities for caring for siblings

at home and other household responsibilities.3

A large proportion of adolescent girls suffer from various

gynecological problems, particularly menstrual irregularities such as

menorrhagia, polymenorrhea, oligomenorrhea, and dysmenorrhea. As many

26
as 40–45% of adolescent girls report menstrual problems. These are mainly

due to psychosocial stress and emotional changes.3

Indian culture promotes universal marriage. Of importance to

Adolescent Reproductive Health is the traditional young marriage age of

girls - referred to as early marriage. The national average age at marriage for

women in India is 16.4 years, although there are vast regional variations.3

NFHS-2 reports that in states like Rajasthan, Bihar, Uttar Pradesh,

Madhya Pradesh, and Andhra Pradesh, girls are married at around age of

15years. According to NFHS-2, about one-third of women were married by

age 15 and two-thirds (64.6 percent) by age 18.3

Teenage pregnancy is the major cause of poor reproductive health and

health outcomes among adolescents. About 15 % of pregnancies are among

teenage girls under age 18 and they have a 2-5 times higher risk of maternal

death. Adolescent pregnant mothers, who are often already poorly nourished

before becoming pregnant, run a high obstetric risk for premature delivery,

giving birth to a low birth weight baby, prolonged and obstructed labour,

and severe intrapartum and postpartum hemorrhage. 3

Programmes and Schemes for adolescent girls implemented by

Government of India

27
 Important relevant policies and plans that have been developed in

India over the past 25 years include, RCH Services Program, Integrated

Child Development Services (ICDS) Scheme, Adolescent Girl Scheme,

State Plans of Action for the Girl Child, District Primary Education

Program, Balika Samriddhi Yojana, 1997, National Plan of Action for the

SAARC Decade of the Girl Child (1991–2000), International Center for

Research on Women (ICRW)3, The Children’s Code Bill, 2000,National

Health Policy, 1983,National Nutrition Policy, 1993, The National Youth

Policy, 1986 (New Draft NationalYouth Policy, 2000) placed adolescent

health as a subsection under the health sector. Youth empowerment and

gender justice were recognized as the major thrust areas of the policy.3.

Apart from various policies, several legislative provisions have also

been introduced that directly or indirectly protect the rights of adolescents.

Besides constitutional provisions, some other legislative acts have been

promulgated to safeguard the health and social protection of children, such

as the Immoral Traffic (Prevention) Act, 1956; the Child Marriage Restraint

Act, 1976; the Juvenile Justice Act, 1986; and the Child Labour (Prohibition

and Regulation) Act, 1986. More recently, the Prenatal Diagnostic

Techniques (Regulation and Prevention of Misuse) Act of 1994 has been

promulgated to prevent selective female feticide.3

28
 In view of the above it is felt necessary to bring in greater synergy

between the resources and programmes of all agencies both Governmental

as well as Non-Governmental, achieve a higher degree of convergence with

other programmes of similar nature in the education, rural development and

health sectors and evolve a strategy for the growth and development of the

Adolescent Girls so that they can be productive and useful members of

society. While there are inter-state and inter-regional variations in the status

of the Adolescent girls, one common threat faced by the Adolescent girls is

the low levels of iron and folic acid, leading to nutritional anaemia and low

health status.4

Overview of Education in India and the Extent of Social exclusion in

Scheduled Caste Children

“Social exclusion reflects the multiple and overlapping nature of the

disadvantages experienced by certain groups and categories of the

population, with social identity as the central axis of their exclusion.”

Constitutional amendment recognizes education as a fundamental right of all

Indian citizens. Even after 60 years of independence disparities continue to

be pronounced between the various castes.14

People from the Scheduled Castes, previously referred to as the

“untouchables”, make up 16% of the population and consistently fare poorer

across various indicators related to primary education. Development

29
approaches from the 1950s to the 1980s primarily focused on social and

economic development as an outcome of the development process and were

less concerned with civil and political rights. In contrast, the human rights

based approach to development recognizes both the achievement of a

desirable outcome and the establishment of an adequate process to achieve

and sustain that outcome.14

A rights perspective is based on principles that emphasize

accountability of those with obligations to realize the rights of children. The

state and the other ‘duty-bearers’ (eg. parents and teachers) have obligations

to fulfill these rights. As rights-holders, children are entitled to demand that

the duty-bearers meet their respective obligation to respect, protect and

fulfill their rights.14

This global shift in development towards a human rights perspective

has important implications for addressing social exclusion in education as it

encourages one to take a broader, systemic and more holistic view of the

issue. Poverty is not merely a lack of income but rather a condition of living

in various forms of deprivation, social exclusion is not only a development

issue, but is also a human rights issue and therefore requires a more

comprehensive and process-oriented response.

30
 As per the Census 2001, the total population of the Scheduled Castes

(SC) in India is 166,635,700, which is 16.3% of the total population

(Registrar General, 2005).14

The population of SCs is unevenly distributed among the states in

India, with nearly 60% of all SC children of primary school-going age (6-10

years) residing in the following six states: Andhra Pradesh, Bihar, Madhya

Pradesh, Orissa, Rajasthan and Uttar Pradesh. The latter five states are

among the most disadvantaged states in India across most social indicators.
15
In an average for India, 27.09% of the population live below the poverty

line in rural areas, compared to 36.25% of the SC population and 23.62% in

urban areas compared to 38.47% of the SC population. These provisions

need to be fully utilised for the benefit of these weaker sections in our

society.14

However, the gap between upper and lower castes children with

respect to completion of primary education is still persisting due to various

socio economic factors. Scheduled caste (SC) children remain disadvantaged

across many social indicators. Estimates from the National Family Health

Survey III (2005-06) suggest that 28 % of the SC population belong to

lowest wealth quintile households. The disadvantaged children have suffered

from multiple forms of disadvantages, example being SC, girls, poor, living

in a poor and/or remote location, etc. Just 21% of SC children have

31
completed primary education compared to 70% of children belonging to

other castes.15

Only 65.7% of SC children of age 7-17 are currently attending school

compared to 81.3% of higher caste groups. Furthermore, 20.8% of SC

children never attended school compared to 7.6% of children from high

caste.14

Evolution of social welfare services

With the attainment of freedom in 1947 and adoption of constitution

in 1950, India became a welfare state. The constitution makers drew up a

preamble which states specifically, that state shall secure for all citizens,

justice, social, economic and political, liberty of thought and expression,

faith and worship, equality of status and opportunity. The fundamental

principles of state policy in the Indian constitution became the basis of social

services / welfare programmes.

The Central Social Welfare Board came into existence in 1953 with a

main purpose of assisting voluntary organizations with requisite grants. The

Department of Social Welfare was setup for first time in 1966. In pursuit of

the goal, the government distinguished between the social service needs of

32
the general population and the special needs of the large groups who have

traditionally suffered social disabilities such as SCs and STs. The central

Government therefore appointed a special commissioner for SCs and STs. It

has also created organizational infrastructure for the welfare of the SCs and

STs in the ministry of home affairs. A commission for SCs and STs was also

set up. 7

There has been a significant increase in overall literacy rates and

school participation rates across the country since the early 1990s. Gender

and social disparities have also declined with an overall increase in school

attendance. The country is approaching near universalisation of enrolment at

the primary stage.

A number of factors have contributed to the rising enrollment rate

including the introduction of mid-day meals, opening of alternate schools,

promoting the participation of Parent Teacher Associations (PTAs) and

massive enrolment drives.

Special provisions: After independence, the Government of India has

taken number of steps to strengthen the educational base of the persons

belonging to the Scheduled Castes and Scheduled Tribes. Pursuant to the

National Policy on Education (1986) and the Programme of Action (POA)-

1992, the following special provisions for SCs and STs have been

33
incorporated in the existing schemes of the Departments of Elementary

Education and Literacy and Secondary and Higher Education.

Sarva Shiksha Abhiyan (SSA): Is a historic stride towards achieving

the long cherished goal of Universalisation of Elementary Education (UEE).

SSA aims to provide useful and quality elementary education to all children

in the 6-14 age groups by 2010.16 Some of the main features of the

programme are:

• Focus on girls, especially belonging to SC/ST communities and

minority groups.

• Back to school campus for out of school girls.

• Free textbooks for girls.16

District Primary Education Programme (DPEP) –

The thrust of the scheme is on disadvantaged groups like girls,

SCs/STs, working children, urban deprived children, disabled children, etc.

There are specific strategies for girls and SCs/STs; as well. According to a

study conducted in schools of DPEP districts, more than 60% students

belonged to SC/ST communities.16

Administration of social welfare hostels in Andhrapradesh

34
 In Andhrapradesh, the welfare programmes for the Scheduled Castes

are looked after by the Education and Social welfare department. On the

executive side, there is a Director of social welfare who is ex-officio Deputy

Secretary to the department of education and social welfare. At the district

level a Deputy Director of social welfare will implement the programmes for

the SCs including the hostels. The District Collector as the administrative

head of the district looks after the welfare programmes. Assistant social

welfare officer will look after the management of the hostels in his region.

One hostel welfare officer (warden) and one care taker will look after the

needs of the children in each hostel. Composition of children in social

welfare hostels is as follows

Scheduled castes - 70%

Christians converted from SC - 12%
Backward classes - 9%
Scheduled tribes - 5%
Others - 4%
At present there are 2210 hostels (Boys 1677 and Girls 533) in the

state with sanctioned strength of 2.46 lakhs at the rate of 100 per each

hostel.17

The aim of these hostels is to give the triple dimension of the teacher,

the taught and the parent (Wardens, Matrons in place of the parents) and to

promote and level up the SC children’s education on par with other castes.18

35
Hostel Facilities for SC Students

• The hostels function for 10 1/2 months and even further in the

summer for implementing various educational schemes.

• There is uniform time schedule for all these hostels for the day to day

programme of academic and other routine of the boarders.

• Also, there is uniform menu for all the hostels at the rate of Rs. 270/-

per month for the classes I to VII and Rs. 330/- per month per boarder

for the classes VIII to X.

• The boarders are also provided with facilities like soaps, hair oil, text

books, note books, bedding material, trunk boxes plates and glasses

etc. free of cost. Cosmetic charges are enhanced from Rs. 10/-per

month to Rs. 20/- per month for boys and from Rs. 12/- and Rs. 17/-

per month to Rs. 25/-per month for girls.

• Necessary provision is also made towards purchase of medicines to

the boarders in the Government hostels. Individual Health cards (HAI

cards) to each boarder have been introduced to facilitate the visiting

medical officer to record his findings in respect of sick boarders for

taking up necessary follow up action (Department of social welfare,

Hyderabad, 2000).

36
 • There are 79 Ananda Nilayams functioning to accommodate the

children of those engaged in unclean occupation and orphan children

in the ratio of 50:50. These institutions run on par with hostels and are

being run in summer vacation also.18

Review of studies on Adolescent Health

Health Status:

In a study conducted in social welfare hostels of Tirupati town

on 598 children aged 6-17 years, the common morbid conditions found were

skin disorders 25.7%,dental caries 21.5%, history of passing worms in stool

21.6% , vitamin B deficiency3.2% ,ARI 1.7% and diarrhea 1.2%. The

prevalence of anaemia and helminthiasis was found to be 79.6% and 39.3%

respectively. In the follow up study, the major health problems reported

were ARI, skin disease, injuries, vitamin .B complex deficiency, diarrhoea

and eye diseases.7

In a study conducted in slums of Lucknow on 400 adolescent girls

aged 10-19 years. 233 (58.2%) girls had attained menarche and the mean age

at menarche was 13.3 years. The mean height and mean weight in all age

groups was less than ICMR standards. The mean hemoglobin was 10 gm%.

Deficiency signs of vitamins were found in 28.7%; 22.2% showed Iron

deficiency signs and 3% had signs of vitamin A deficiency. The various

37
morbid conditions found among girls were inadequate oral hygiene (55.4%),

pediculosis (39.2%), cold & cough (25.8%), lymphadenopathy (22.2%),

scabies (16.2%), inflamed tonsils (7.8%) and ear discharge (7%).19

In a study on Health Status of School Children in Ludhiana City 776

students of both sexes (462 boys and 314 girls), in the age group 5-16 years,

from a secondary school in Ludhiana were examined. The health and

nutritional standards of the school children were found to be low, more so in

girls than in boys. The extent of malnutrition in this group was high, with the

children in nearly all ages, both boys and girls, being deficient in both

weight and height as compared to the ICMR standards. The prevalence of

wasting and stunting in these children was high (52.2% wasted and 26.3%

stunted) with boys and girls suffering almost equally. The prevalence of

anaemia was high in both sexes of adolescents, though significantly more so

in girls (30.5%) than in boys (22.9%). Malnutrition and anaemia make the

adolescents more susceptible to infection.20

In a Study of Health Problems of Adolescents in Urban Field Practice

Area of Nagpur, in the 10-20 years age group, 700 adolescents were studied.

Age of menarche in females ranged from 10 - 17 years, with majority having

attained it at the age of 13years. Menstrual problems, including

oligomenorrhoea were present in 30% adolescents. 439 (62.71%)

adolescents were suffering from acute nasopharyngitis / acute tonsillitis and

38
401 (57.28%) from anaemia. 379 (54.14%) were having acne, 259 (37.0%)

were having dental caries, 240 (34.28%) were having nicotine stains on

teeth. 184 (26.28%) adolescents were having signs of vitamin B complex

deficiency, 136 (19.42%) had history of passing worms in stools, 45 (6.43%)

adolescents had scabies, 52 (7.43%) pediculosis, 25 (3.57%) obesity and 2

(0.28%) were known cases of congenital heart diseases (CHD). Out of 700

adolescents, 401 (57.28%) were anaemic, with 117 (16.71%) having

moderate and 284 (40.57%) having mild anaemia. Higher prevalence of

anaemia was seen in female adolescents 219 (60.16%) as compared to male

adolescents182 (54.16%). The percentage of morbid conditions were higher

in joint families (82.42%) as compared to nuclear families (61.08%), due to

overcrowding and poor sanitation.21

In a study in rural Tamil Nadu, the prevalence of cold and headache

was 16.62 % and 10.23% respectively. About 7.67% of the girls surveyed

had non-specific fever and another 8% had digestive problems. 12% of the

girls reported body pains and backache. The prevalence of general morbidity

increased with age and it was high among illiterate than literates. 46% had

reproductive morbidity, 5% had general illness and 37 % had both general

and reproductive illness.22

In a study conducted in Mumbai among 1,144 girls of 5-15 years age,

630 of primary section and 514 of secondary section of affluent population,

39
the commonest health problems noted in these girls were related to hygiene

(62.2%). While dental caries and helminthiasis were commoner in younger

girls, pediculosis was most frequently seen in older girls of secondary

section. Nutritional disorders were present in 29.0%.Other important health

problems included asthma (6.6%), hypertension (2.2%), otitis media (2.0%),

splenomegaly (1.6%), ocular infections (1.5%), cervical lymphadenopathy

(1.1 %), tuberculosis (0.8%), cardiac disease (0.5%), deafness (0.4%),

epilepsy (0.4%) and UTI (0.4%). Among the six cardiac lesions, two were

rheumatic in origin.23

In a study done in the Kaniyambadi Block of North Arcot District of

Tamil Nadu, a total of 190 adolescents were studied. The five leading

general complaints were general fatigue, palpitations, frequent headaches,

backaches and abdominal pain (not related to menstruation). Over 20%

seemed to suffer from joint pains, weight loss, poor appetite and recurrent

respiratory problems. Sleep disturbances, loss of weight, frequent headaches

and dermatological problems were more common among those who had

attained menarche. Heights of adolescent girls varied from 140 to 151 cm

and weights from 31 to 43 kg. Pubertal spurts were seen between 13 to 14

years. The heights and weights were less than the 5th percentile of National

center for Health statistics. The body mass index varied from 16 to 19 and

40
generally depicts an undernourished population. One hundred and twenty

four of the girls had attained menarche, the mean age being 13.9 years.24

In a study conducted in Pondicherry, the morbidity of 5,602

adolescents aged 10-19 years was studied; diseases of the eye, ear, nose,

throat and skin, and upper respiratory infections were found in 70%. Injuries

seem to be the next important cause of morbidity amongst adolescents.

Dysentery seems to occupy a less important place in the morbidity figures of

adolescents in comparison with that of infants and children. Accidents seem

to be the leading cause of death amongst the adolescent population of all

countries. Malignant neoplasms, including neoplasms of tissues seems to be

the second most important cause of death amongst the adolescent population

of the developed countries.25

In a clinical survey of 916 school children in a rural area in Western

Orissa for B.C.G. immunization coverage; coverage was found as 69.5 per

cent. Anthropometric measurements revealed that the height of these

children was more than the ICMR standard while weight was lower than the

ICMR standard. Chest circumference was more or less similar to the ICMR

standard. Common causes of morbidity were vitamin B complex deficiency

(42.9%), vitamin A deficiency (28.6%), anaemia (25.7%), upper respiratory

tract infections (22.1%), gastro-intestinal tract disorders (8.7%), scabies

(16%) and dental diseases (8.5%).26

41
 A cross sectional study was undertaken on 640 Relli boys and 671

Relli girls aged between 10 to 18 years in urban schools situated in

Visakhapatnam The study revealed that Relli girls attained maximum mean

annual increase between 10 and 12 years and boys between 14 and 16 years.

The Relli boys and girls were taller and heavier than ICMR (1984) National

standards.27

In a cross-sectional study conducted in Boileaugang, Shimla during

June 2002 to January 2003 among 870 adolescents of age 10-19 years (480

males and 390 females), anaemia was diagnosed clinically in 62 (12.9%)

males and 52 (13.3%) females with an overall prevalence of 13.1%. 48

(77.4%) anaemic males and 33 (63.5%) anaemic females had poor personal

hygiene. Among females, 44 (84.6%) anaemic subjects had history of worm

infestation as compared to 147(43.8%) non-anaemic females (p<0.001). It

was also seen that, 30 (53.6%) anaemic females had menstrual problems like

menorrhagia, polymenorrhea, or irregular menstrual cycle as compared to 22

(6.6%) non-anaemic females. Prevalence of anaemia was 14.9% (15.5% in

males and 14.3% in females).28

Nutritional Status

In a cross sectional study carried out in tea gardens of Dibrugarh

district of Assam, in 605 adolescents aged 10-18years, the prevalence of

42
thinness in boys was 59.49% and in girls 41.32%. Mean BMI values of both

boys and girls were far below the NCHS median. Over weight was present

in 0.33%.29

In a study conducted in two PHC areas of Wardha district in

adolescents, 53.8% were thin, 44% were normal, and 2.2% were over

weight. The mean BMI for boys and girls was 16.88kg/m² and 15.44 kg/m²

respectively.30

In a study conducted by NNMB (1996-97) in 120 villages from each

state, overall prevalence of stunting (< median height-2 SD) was similar in

both the sexes, boys: 39.5% and girls: 39.1%. Under nutrition (< median-

2SD of NCHS weight for age) in males was more (53.1%) as compared to

females (39.5%) in case of body weight. The mean daily intake of different

foods according to sex were almost similar in both the sexes. The percentage

of under nutrition was less in adolescents belonging to extended families

(40.7%) as compared to joint families (48.6%).31

In a study conducted in adolescent rural girls of Varanasi, two-third of

study subjects were undernourished (BMI < 18.5 kg/m2), nearly one-third

had chronic energy deficiency grade-III (BMI<16 kg/m2).53.33%

adolescent girls had normal built. Vitamin A, B, C and D deficiencies were

present in 13.70%, 4.07%, 15.92% and 10% study subjects respectively.

Bitot’s spots were seen in 3.33% subjects and 25.90%, 13.33% and 4.44 %

43
girls had anaemia, dental caries and Iodine Deficiency Disorders (IDDs)

respectively. Nearly one-third girls were anaemic (Hb < 12 g/dl). Anaemia

was significantly more in non-menstruating girls and subjects not using

footwear during defecation.32

In a community-based survey carried out by NNMB (2000) on rural

males and females, up to 22 years of age from eight states, showed the

prevalence of Bitot’s spot in females (12-21 years) declined from 1.8 to

1.3%. The prevalence of goitre reduced from 5.8% to 3.0% during 1998-99

when compared to 1985-87 surveys in respect of all states, as revealed by

the pooled data. Overall dietary intake of iron had declined in all age groups

(1-3, 4-6, 7-9, 10-12 and 13-15 years) as per 1998-99 surveys when

compared with 1985-87 surveys.33

In a Study of growth parameters and prevalence of overweight and

obesity in school children from Delhi, total of 21,485 children in the age

group 5 to 18 years were evaluated for height, weight and BMI. The

prevalence of overweight and obesity among the lower socio economic

status school girls was 2.14% and 0.28% as compared to 19.01% and 5.73%

respectively among girls from upper socio economic status. There is a

significant disparity in anthropometric parameters of children belonging to

the upper and lower socioeconomic strata, with upper socio economic status

children being significantly taller and heavier.34

44
 In a study conducted in adolescent girls between 10 and 15 years of

age, studying in 6th to 10th standards in 16 high schools located in two

randomly selected Mandals of Medak district, signs and symptoms of

anaemia like pallor (eyes, tongue nails), fatigue, breathlessness, poor

appetite and lack of concentration in studies were reported by 12.5%, 14.1%,

9.2%, 26.5% and 86% of girls respectively. Iron deficiency anaemia was

found in 81% of respondents. Mild, moderate and severe grades of anaemia

were observed in 63.2%, 12.5% and 5.3% of respondents respectively. The

heights and weights of study subjects at any given point of age were far

below the NCHS standards. Haemoglobin level improved in 45.6% while it

remained static in 49.4 % and declined in only 5 % of subjects.35

In a study among 504 adolescent Girls in rural Areas of District

Meerut (UP), 174 (34.5%) adolescent girls were anaemic. The prevalence of

mild, moderate and severe anaemia among adolescent girls was 19%, 14.1%

and 1.4%, respectively. The proportion of mild, moderate and severe

anaemia was 55.2%, 40.8% and 4.0% respectively. The significant

association of anaemia with socio-economic status, type of family, father’s

occupation, mother’s education and family size stressed the need to develop

strategies for intensive adult education, nutrition education and dietary

supplementation, including anaemia prophylaxis.36

45
 In a study conducted in orphanages located in Udaipur city, the

average amount of cereals consumed by the boys of different age group was

76.2% - 91.5% of the requirements, whereas intake of pulses was only 30%

of the suggested quantities. The leafy vegetables were rarely supplied to the

children but intake of other vegetables was more than the recommended.

Intake of fats and oils was observed to be 30-45% less than what it is

suggested. The milk intake by children was insufficient. Food items like

fruits, meat, fish and eggs were never included in the diet provided in the

orphanages. All the children received significantly less than the

recommended intake of iron.37

Indian Council of Medical Research (ICMR) had undertaken a

multicentre, Community-based study “District Nutrition Project” in 18

districts from 13 states of the country including rural and urban children

(< 12 years), adolescent girls (11-18 years) and pregnant women. Prevalence

of anaemia among 4,332 non-pregnant adolescent girls from 16 districts was

90.1%. The range was 58.2 % to 100% .Average prevalence of anaemia in

the eight districts of northern India was 89.4 % and in the six districts of

eastern (including north-east) India, it was 91.7%. Mild and moderate

anaemia is more prevalent than severe anaemia.38

In a study carried out among 1295 girls of school going age (6-18

years) residing in 15 randomly selected slums of the north Ahmedabad city,

46
81.8% of girls were anaemic, out of which 55.2 % were mildly anaemic,

0.6% severely anaemic and the rest were moderately anaemic No significant

relationship of anaemia was observed with socio-economic class, knowledge

about anaemia, and parent’s education, status of menstruation and daily

consumption of lemon/ sour fruits. Anaemia was found to be significantly

higher among girls with a habit of post meal consumption of tea / coffee

(94.4%), whose fathers were working as semi-skilled/skilled workers (77%),

those having a BMI of 18.5 or lower (82.4%), as compared to those with

BMI more than 18.5(79.7%). The prevalence of anaemia was significantly

lower in girls consuming green leafy vegetables.39

In the study conducted by ICRW on the Nutrition of Adolescent Girls

in five developing countries including India, which was done in Bombay

urban slums in 69 Males and 69 Females of 10-19 years, 55% were anaemic,

32% were stunted and 53% were under nourished.40

In a study conducted in a rural area of West Bengal, in 143 adolescent

girls of 10-19 years, prevalence of thinness was 14.7%, 37.8% were stunted,

44.8% were anaemic, dental caries in 25.9% and 15.4% with angular

stomatitis, goiter in 1.4%. The prevalence of stunting was significantly

higher among the late adolescent age group than in early adolescent age

group.41

47
 In a study conducted in 360 school going adolescent girls of 13-18

years age group of Raipur city, the prevalence of anaemia was 82%. The

subjects of the experimental group were provided with different types of

supplementation. The study revealed that role of Iron and Folic acid twice a

week supplementation is important in improving the level of anaemic

adolescent girls.42

In a study conducted in 454 girls, of 11-18 years age group in Delhi, it

was observed that 35.5% were under nourished, 3.1% were obese. Anaemia

was found in 56% and dental caries in 23.3%.43

48
MATERIAL
AND
METHODS

49
Municipal Corporation Map of Nellore Showing
Social Welfare Hostels

50
 MATERIAL AND METHODS

Description of the study area

Nellore District is one of the 23 districts of Andhra Pradesh. Nellore is

famous for high paddy field, and so it got its name from the word (paddy)

"nelli".44 The population of the district was 2,668,564 of which 22.45% were

urban as of 2001. Nellore city is its administrative headquarters. The major

cities in the district are Nellore, Kavali and Gudur.

The study was conducted in five social welfare hostels and Ananda

Nilayam located near Madras bus stand within a radius of half a kilometer.

All the hostels except one are housed in Government buildings. Three

hostels are located in a single building but having kitchen and storage room

in separate blocks in the same compound. The other two girl’s hostels are

located as separate unit. The staffing pattern of hostel consists of one

warden, one care taker and three kitchen staff in addition to one sweeper and

one watchman.

The girls in the hostels are attending three primary schools, one high

school and three colleges in the neighbourhood. The medical officer of the

school health clinic provides medical checkup and treatment for children

once in a month. Those requiring specialist treatments will be referred to

district hospital. There is a provision for reimbursement of the amount

51
incurred for the purchase of medical aids like spectacles prescribed by the

specialist for the children.

Study setting: Social welfare hostels for scheduled caste girls in

Nellore city.

Study design: Descriptive cross sectional study.

Study period: June 2008 –May 2009.

Study population: All the girls aged between 11-19 years residing in

the social welfare hostels of Nellore city.

Inclusion criteria: 1.All adolescent girls aged 11-19 years.

2. A minimum of not less than one year stay in the

hostel.

Exclusion criteria: Absentees and drop outs of the subjects from the hostel

during the period of survey.

Sample size: 562 adolescent girls were registered at the time of study in

social welfare hostels out of which 542 are recruited in this study.

Study instruments: Pre-designed, pre-tested, semi-structured questionnaire,

stethoscope, sphygmomanometer, Snellen chart, Weighing machine,

stadiometer etc.

Study methodology: The study was conducted among adolescent girls

residing in six social welfare hostels for scheduled caste students in Nellore.

52
Among these six hostels four are for school children, one is Anandanilayam

(orphanage) and one for college girls. Written permission was obtained from

the Deputy Director of social welfare hostels of Nellore district. The study

was conducted with the co-operation of the hostel welfare officers.

Morbidity Status

Data regarding morbidity status was collected using a pre-designed,

pre- tested proforma (Annexure-1).Every girl was examined physically from

head to toe and deviations from normal were recorded. Enquiry was made

about the education and occupation of the parents, duration of stay in the

hostel, practices regarding personal hygiene, menstrual history, menstrual

hygiene and occurrence of any ailment during previous two weeks.

Nutritional Status

Nutritional status of girls was assessed by:

• Anthropometric measurements viz height, weight, BMI.

• Biochemical markers viz haemoglobin estimation.

• Diet survey.

Anthropometry45

53
 Height- Stadiometer (measuring rod) capable of measuring to an

accuracy of 0.1 cm was used to assess height of the subjects. The subject

was made to stand without foot wear with the feet parallel and with heels,

buttocks, shoulders, and occiput touching the measuring rod, hands hanging

by the sides. The head was held comfortably upright with the top the head

making firm contact with the horizontal head piece.

Weight- A portable weighing machine with an accuracy of 100gms

was used to record the weight of the girls. Checking the scale with a known

weight was done frequently and adjustment to zero was done every time for

accurate reading. Girls were instructed to stand on the weighing machine

with light clothing and without footwear and with feet apart and looking

straight and weight was recorded to the nearest value.

Body Mass Index (BMI) – BMI was calculated using the formula

Weight in kg/height in m²

The subjects were categorized into four groups based on BMI according to

WHO Asian Pacific46 standards as

<18.5 kg/m2 - Chronic energy deficiency or under weight

18.5-22.99 kg/m2 - Normal

23 – 24.99 kg/m2 - Over weight

54
 > 25 kg/m2 - Obese

Thinness- WHO defines thinness in adolescents as BMI below the 5th

centile for age.47 In this study, 5th percentile of NCHS standards of BMI for

age were considered as thin.

Wasting - Height for age less than 3rd percentile of NCHS/WHO standards.48

In this study, 5th percentile of NCHS standards of height for age were

considered as stunted or wasted.

Diet survey – A diet survey as a part of nutritional assessment was

conducted by weighment of raw foods. This method is widely employed, as

it is practicable, fairly accurate and specially suited to institutions. Diet

survey was carried out for one dietary cycle of seven days in two hostels

randomly. Weighment of raw foods was done three times in a day (6.00AM,

10.00AM and 4.30 PM) preceding breakfast, lunch and dinner. The weights

of bulk items like rice, pulses etc.were recorded by an Avery weighing scale.

For any item below 1 kg, a small weighing scale was used. The number of

children who dined that day and their ages were recorded.

Daily consumption of calories and important nutrients were calculated

49
using “Nutritive value of Indian Foods” (ICMR) and compared with

recommended balanced diets.

Environmental conditions:

55
 All hostels were visited and information was collected regarding

environmental conditions by inspection using a proforma (Annexure-II).

Laboratory Tests:

Haemoglobin estimation was done by Sahli’s method (Annexure-III)

on a 20% subsample of subjects, drawn by systemic random sampling. The

WHO cut off levels were taken as standards to classify the haemoglobin

status.

Table showing stages of anaemia50

56
Analysis:

Data collected was entered in Microsoft Office Excel and analysed by using

SPSS Version 12.0.

Proportions were calculated for different study variables.

Chi-square test was used for analysis of categorical variables.

Criteria of significance used in the study was p < 0.05.

Listing and Citing of References:

Vancouver’s style was used for listing and citing of references.

57
RESULTS

58
 RESULTS

I. Socio-Demographic Profile
Table1: Demographic background of study subjects (n=542)

Socio-demographic Urban Rural Total Significance

factors (%) (%) (%)
Age group (Years)
11 – 13 60(18.81) 259(81.19) 319(100) χ² = 1.88
14 – 15 21(12.88) 142(87.22) 163(100)
df = 2
16 – 19 8(13.33) 52(86.67) 60(100)
p = 0.39
Total 89(16.42) 453(83.58) 542(100)
Type of family
Nuclear 64(14.95) 364(85.05) 428(100) χ² = 3.21
Joint 24(21.82) 86(78.18) 110(100)
df = 2
Three – generation 1(25) 3(75) 4(100)
p = 0.2
Total 89(16.42) 453(83.58) 542(100)
Family size
< 4 members 31(18.23) 139(81.77) 170(100) χ² = 1.7
4-6 members 42(14.29) 252(85.71) 294(100)
df = 2
>6 members 16(20.51) 62(79.49) 78(100
p = 0.43
Total 89(16.42) 453(83.58) 542(100)

Majority of the girls were from rural background (83.58%). The

present study revealed that irrespective of the area majority belonged to

nuclear families (78.97%). Majority of the study subjects are having a

59
average family size of 4-6 (54.2%). There is no significant difference

between urban and rural areas for the above Socio-demographic factors.

Table2: Educational background of parents of study subjects (n=542)

Urban (%) Rural (%) Total (%) Significance

Mother’s education
Illiterate 41(15.59) 222(84.41) 263(100) χ² = 3.12
School educated 44(16.73) 219(83.27) 263(100)
df = 2
College 4 (25) 12(75) 16(100)
p = 0.2
educated
Total 89(16.42) 453(83.58) 542 (100)
Father’s education
Illiterate 41(15.59) 222(84.41) 263(100) χ² = 25.92
School educated 42(15.85) 223(84.15) 265(100)
df = 2
College 6(42.86) 8(57.14) 14(100)
p = 0.00
educated
Total 89(16.42) 453(83.58) 542 (100)

Majority of mothers from rural areas were illiterate (41%) and in

urban areas majority were school educated (8.1%). On the other hand

nearly41.1% fathers from rural areas were educated up to school level

followed by illiterates (41%).In case of urban areas number of fathers with

illiterate and school educated were almost equal. When compared with

mothers and fathers, maximum numbers of fathers were school educated

where as equal numbers of mothers were illiterate and school educated.

There is significant difference between urban and rural areas for father’s

education.

60
Table3: Occupational background of parents of study subjects (n=542)

Mother’s Urban (%) Rural (%) Total (%) Significance

occupation
Home maker 35(26.51) 97(73.49) 132(100) χ² = 63.73
Labour 32(9.64) 300(90.36) 332(100)
df = 3
Service 16(23.53) 52(76.47) 68(100)
Others 6(60) 4(40) 10(100) p = 0.00
Total 89(16.42) 453(83.58) 542 (100)
Father’s occupation
Farming 20(6.87) 271(93.13) 291(100) Χ² = 33.27
Labour 26(21.67) 94(78.33) 120(100)
df = 3
Service 31(41.33) 44(58.67) 75(100)
Others 12(21.43) 44(78.57) 56(100) p =0.00
Total 89(16.42) 453(83.58) 542 (100)

When considered in terms of mother’s occupation 61.25 % were

labourers followed by home maker (17.9%) in rural areas. 72.14% of

father’s were farmers followed by 22.14% labourers, 13.84% service and

10.32% others. There is significant difference between urban and rural

areas for mother’s and father’s occupation.

61
Table4: Educational status of study subjects (n=542)

Educational status Frequency Percentage

Middle school 194 35.79
High school 304 56.08
College education 44 8.11
Total 542 100

On the whole 35.79% were in middle school, 56.08% were in high school,
8.11%were in college education.

Table5: Duration of Stay of study subjects in the hostel (n=542)

Period of stay Total (%)

(years)
<5 466 (85.97)
>5 76 (14.03)
Total 542 (100)

The study shows that majority of girls stayed less than five years in

the hostel.

62
 II. MORBIDITY STATUS

Table 6: Current morbidity profile of study subjects (n = 542)

Morbidity Frequency Percentage

1 Pediculosis 451 83.21
2 Dysmenorrhea (n=273) 119 43.6
3 Pallor 223 41.14
4 Dental caries 152 28.04
5 Skin disorders 143 26.4
6 Vitamin deficiency 117 21.57
7 Passing worms in the stools 72 13.28
8 Defective vision 67 12.36
9 ENT disorders 38 7.01
1 Inflamed Gums 25 4.61
0
1 Respiratory infections 26 4.85
1
1 Diarrhoea 14 2.58
2
1 Cardiovascular disorders 6 1.11
3
1 Musculoskelet al. disorders 5 0.9
4
1 Lymphadenopathy 4 0.73
5
1 Having one or more morbid conditions 482 88.93
6

The major prevalent morbid conditions among girls were Pediculosis

83.21%, Dysmenorrhea 43.6% Dental caries 28.04%, Skin disorders 26.4%

(scabies-20.84%, eczema-2%, ulcers-2%, warts-1.56%) Vitamin deficiency

21.57%(vitamin A - 0.74%, vitamin B- 7.93%, vitamin C- 11.44%, vitamin

63
B&C- 1.46%), clinical anaemia 41.14% and defective vision 12.36% .On the

whole 88.93% of the girls were having one or more morbid conditions,

11.07% were free from any recognizable morbidity.

Table7: Morbidity pattern of study subjects across age groups (n=542)

Age group in years

11-13 14-15 16-19
(n=319) (n=163) (n=60)
Morbidity P value
Frequency Frequency Frequency
(%) (%) (%)
Pediculosis 281(88.1) 132(81) 38(63.3) 0.00(HS)*
Poor personal 159(49.8) 69(42.3) 19(31.7) 0.04 (S)#
hygiene
Pallor 141(44.2) 56(34.3) 26(43.3) 0.28(NS)§
Skin disorders 97(30.4) 36(22.1) 10(16.7) 0.09(NS)§
Vitamin deficiency 73(22.8) 27(16.5) 15(25) 0.36(NS)§
Defective vision 30(9.4) 31(19) 8(13.3) 0.11(NS)§
ENT disorders 19(5.9) 15(9.2) 4(15) 0.01 (S)#
Respiratory 16(5) 8(5) 2(3.33) 0.72(NS)§
disorders
Dysmenorrhea 27(35.5) 52(37.96) 40(66.7) 0.00(HS)*
(n=76) (n=137) (n=60)
# § *
S -significant; NS -not significant; HS -highly significant.

Pediculosis, poor personal hygiene and dysmenorrhea were found to

have significance across the age groups. High morbidity was found in 11-13

year age group.

Table 8: Illness of study subjects in past two weeks (n = 542)

Illness in last 2 weeks Frequency Percentage

Pyrexia 229 42.25
Scabies 91 16.79
64
 Diarrohea 60 11.07
Acute respiratory infections 36 6.64
Exanthematous fever 21 3.87
Dysmenorrhea 18 3.32
Having one or more illness 446 82.3

In 542 subjects, 17.7% did not report any illness in the past two

weeks, 446 (82.3%) reported illness in the past two weeks. 42.25% suffered

from pyrexia, followed by 16.79% scabies, 11.07% diarrohea and 6.64%

acute respiratory infections.

65
III. Menstrual Health

Table 9: Age at Menarche of study subjects (n = 273)

Age (years) Frequency Percentage

10 2 0.7
11 5 1.8
12 81 29.7
13 91 33.3
14 70 25.6
15 23 8.4
16 1 0.4
Total 273 100

Out of 542 girls, 273 (50.36%) attained menarche. Majority of them

attained menarche at the age of 13 years (33.3%) followed by 12 years

(29.7%) and 14 years (25.6%).

66
 Table10: Menstrual pattern of study subjects (n=273)

Menstrual cycle Frequency Percentag

e
Regular 171 62.6
Irregular 102 37.4
Bleeding during menstruation
<3 days 18 6.6
3-5 days 211 77.3
6-7 days 36 13.2
>7 days 8 2.9
Dysmenorrhea
Never 154 56.4
Occasionally 30 11
Frequently 12 4.4
Always 77 28.2
PreMenstrualTension
Never 231 84.6
Occasionally 14 5.1
Frequently 2 0.7
Always 26 9.5
Breast pain during menstruation
Never 255 93.4
Occasionally 6 2.2
Frequently 2 0.7
Always 10 3.7

This table shows the menstrual pattern in 273 girls who attained

menarche. 62.2% had regular menstrual cycle, 77.3% had an average of 3-5

days of menstrual bleeding. 28.2% always suffered from dysmenorrhea .

9.5% always suffered from premenstrual tension. 3.7% always suffered from

breast pain during menstruation.

Table 11: Menstrual hygiene in study subjects (n=273)

67
 Method of disposal Frequency Percentage
Cloth pieces reused 46 16.9
Pads / cloths disposed properly 200 73.3
Pads / cloths disposed 27 9.9
improperly
No. of pads used per day
<2 97 35.5
>2 176 64.5

64.5% used more than two pads per day during menstruation.

Majority of them (73.3%) were using sanitary pads or cloths which are

disposed properly.

68
 III. NUTRITIONAL STATUS

Anthropometric Measurements

Table 12: Age wise distribution of Median weight of study subjects

(n=542)

Age(yrs) Number Median wt(kg) S.D. NCHS(50th percentile)

of girls Weight( kg)
11 78 30 4.69 37
12 102 34 4.85 42
13 139 36 5.18 46
14 112 39 4.67 49
15 51 40 4.84 52
16 22 41.5 8.63 54
17 10 44 4.92 55.30
18 8 45.5 2.10 56.20
19 20 45 2.94 57.20

The median weight of the girl ranged from 30 ± 4.69 Kg to 45.5 ±

2.10 Kg. The median weight increased as the age increased. When compared

to 50th percentile of NCHS standards the mean weights of girls in the present

study were very low. This was significant with a t value of 0.002.

69
Figure1: Line chart showing Weight for Age

Figure2: Line chart showing Height for Age

70
Table 13: Median Height compared with NCHS standards in study
Subjects (n=542)

Age Number Median height(cm) S.D. NCHS(50th percentile)

(years) of girls Height(cm )
11 78 131 6.24 144
12 102 138 6.28 151
13 139 143 5.68 157.5
14 112 147 6.04 161
15 51 149 5.15 162
16 22 154 6.25 162.5
17 10 153.50 2.46 163
18 8 154.5 4.06 163.2
19 20 153.5 4.10 163.5

The median height of the girls ranged from 131 ± 6.24 cm to 154.50 ±

4.06cm. When compared to 50th percentile of NCHS the median height of

girls in the present study were very low. This was significant with a t value

of 0.005.

71
Table14: Prevalence of Stunting in study subjects (n=542)

Age group (Years) Number Stunting

Frequency Percentage
of girls
11 - 13 319 28 8.8
14 – 15 163 24 14.7
16 – 19 60 8 13.3
Total 542 60 11.07
χ²=0.97, df=2, p>0.05

Stunting was highest 14.7% in 14-15 year age group, followed by

13.3% in 16-19 years and 8.8% in 11-13 year age group.

Figure3: Bar diagram showing Prevalence of Thinning and Stunting

Table15: Prevalence of Thinness in study subjects (n=542)

Age group (Years) Number Thinness

Frequency Percentage
of girls
11 - 13 319 162 50.8
14 – 15 163 122 74.8
16 – 19 60 28 46.7
Total 542 312 57.56
χ²=0.62, df=2, p>0.05
The prevalence of thinness in the study subjects was 57.56%. Thinness

was highest in the age group of 14-15 year i.e., 46.7%, followed by 50.8 %

in 11-13 years and 46.7% in 16 – 19 year age group.

72
 Table 16: Distribution of study subjects according to BMI staging
(n=542)
BMI staging Frequency Percentage
1 <18.5(under weight) 350 64.6
2 18.5-22.99(normal) 188 34. 7
3 23-24.99(pre-obese) 2 0.4
4 >25(obese) 2 0.4
Total 542 100

According to WHO BMI staging 64.6% were underweight, 0.4% were

pre-obese and 0.4% were obese.

Figure4: Histogram showing Age and Mean Haemoglobin

The mean haemoglobin of the girls ranged from 10.22±0.5 to

12.6±0.11 gm/dl. The mean haemoglobin level was highest in 18 year age

group.

73
Table 17: Grading of Haemoglobin of study subjects according to WHO
criteria (n=135)

Haemoglobin(gm/dl) Frequency Percentage

1 Normal (>12) 68 50.4
2 Mild Anaemia (7-9.99) 22 16.3
3 Moderate Anaemia (10-11.99) 39 28.9
4 Severe Anaemia (<7) 6 4.4
Total 135 100

A 20% sub-sample of 542 subjects i.e. 135 subjects were examined

for Haemoglobin estimation. 49.6% were found to be anaemic.

Figure5: Pie diagram showing Grading of Haemoglobin

Table 18: Mean Haemoglobin of study subjects according to Menstrual

Status (n=135)

Number Mean Hb S.D 95% CI

Menstrual Status
(%) (gm/dl)
78 (57.77) 11.06 1.5 10.7-11.42
Menstruating
9
57 (42.33) 10.69 2.2 10.11-11.27
Non-menstruating
0
(z=1.12)
Out of 135 girls in whom haemoglobin estimation was done, the mean

haemoglobin in menstruating girls (11.06 ± 1.59 gm/dl) was more than in

non-menstruating girls (10.69 ± 2.20 gm/dl) .The mean difference between

these two groups was found to be not significant. (z=1.12).

74
Table 19: Duration of stay of study subjects in the hostel and Anaemia
(n=135)

Anaemia
Period of
stay Present Absent Total
(years) (%) (%) (%)
<5 40(52) 37(48) 77(100)
>5 27(46.55) 31(53.45) 58(100)
Total 67(49.63) 68(50.37) 135(100)
(χ ²=0.2,df = 1, p = 0.65)

Out of 77 girls who stayed less than five years in the hostel, anaemia

was present in 52% where as in those who stayed more than five years

anaemia was present in 46.55% and this was found to be statistically

insignificant. (χ ²=0.2,df = 1, p = 0.68)

Table 20: Prevalence of Anaemia and Passing worms (n=135)

Passing worms Anaemia

in the stool Present (%) Absent (%) Total (%)
Present 27(84.38) 5(15.62) 32(100)
Absent 40(38.84) 63(61.16) 103(100)
Total (%) 67(49.62) 68(50.38) 135(100)
(df = 1, χ² = 18.474, p <0.001)
In 49.62% of girls who were anaemic 84.38% had the history of

passing worms, where as in 50.38% of girls who were not anaemic,15.62%

have the history of passing worms. This was found to be statistically

significant. (df = 1, χ² = 18.474, p < 0.001)

75
 IV. Diet Survey:

The diet survey, as apart of nutritional assessment was carried out in

two girl’s hostels. The finding of the survey in terms of intake of nutrients

and intake of food articles compared with recommended allowances are

presented here. The requirements of nutrients and food items were computed

by multiplying number of children in each group and the recommended

values for children of corresponding ages.

Table 21: Estimated daily intake of calories and nutrients compared

Vitamin-
Proteins Fats Calcium Iron A Vitamin- Vitamin- Nicotinic Vit
Calories
(gm) (gm) (mg) (mg) Carotene B1 (mg) B2 (mg) acid (mg) C
(µg)
Requirements 1,70,680 5,100 1,870 51,000 1,955 2,04,000 85 102 1,139 3,40
Actual 1,96,628 5,343 2,643 41,800 3,422 6,13,624 279 5,002 899 5,30
consumption
Excess 25,948 243 773 - - 4,09,624 - 654 240 1,90
Deficit - 9,200 1,467 - 194 4,900
with requirements (n=85)

Calories, proteins, Fats, vitamin-A, vitamin- B2, vitamin- C intake was

adequate. The intake of other nutrients was below the actual requirement

76
Table 22: Daily intake of food items compared with requirements in
terms of recommended balanced diets
(n=85)

Cereals Pulses Green leafy Other Fruits Milk Fa

(gm) (gm) vegetables vegetables, (gm) (gm) an
(gm) roots and oi
nuts (gm) (g
Requirements 28,305 5,465.5 10,336 9,095 3,519 18,836 4,
Actual 32,300 6,375 3,400 8920 7,650 1,530 1,
consumption
Excess 3,995 909.5 - - 4,131 -
Deficit - - 6,936 175 - 17,306 2,

Cereals, pulses, fruits and egg intake was adequate whereas the

intake of all other food items were below the recommended levels.

Table 23: Estimated daily intake of calories and nutrients compared

with requirements. (n=140)

Calories Proteins Fats Calcium Iron Vitamin Vitamin Vitam

(gm) (gm) (mg) (mg) -A - B1 -B2
Carotene (mg) (mg)
(µg)
Requirements 2,88,400 9,100 3,080 84,000 3,920 3,36,000 168 140
Actual 4,40,600 4,248 5,300.15 1,65,320 7,899 4,85,241 986.96 7,280
consumption
Excess 1,52,200 - 2,220.15 81,320 3,979 1,49,241 818.96 7,140
Deficit - 4,852 - - - - - -

The intake of all nutrients was adequate except the proteins which was less
than the recommended values.

77
Table 24: Daily intake of food items compared with requirements in
terms of recommended balanced diets.
(n=140)

Cereals Pulses Green Other Fruits Milk F

(gm) (gm) leafy vegetables, (gm) (gm) a
vegetables roots and nuts o
(gm) (gm) (g
Requirements 49,000 7,000 21,000 21,000 4,200 21,000 5
Actual 80,000 8,100 2,000 12,500 15,000 16,000 2
consumption
Excess 31,000 1,100 - - 10,300 -
Deficit - - 19,000 8,500 - 5,000 3

The intake of cereals, pulses, fruits, sugar and Jaggery were

adequate, whereas the intake of all other food items were below the

recommended levels

78
 Table26: Environmental Conditions of Social Welfare Hostels

Girls hostel Girls hostel Girls hostel Girls hostel College Ananda
Sl. Environmental conditions I II III IV hostel nilayam
No (n=165) (n=140) (n=104) (n=165) (n=65) (n=77)
1 Distance from road (mts) 50 50 134 64 64 50
2 Source of noise and dust Present Present Absent Absent Absent Present
3 Floor area per girl (sq.ft) 9.8 11 6 6.4 12 9.7
4 Ventilation (window area) Inadequate Adequate Inadequate Adequate Adequate Adequate
(18%) (21%) (15%) (21%) 42% 45%
5 Indoor lighting Insufficient Sufficient Insufficient Sufficient sufficient sufficient
6 Furniture Not provided Not Not provided Not Not provided Not provided
provided provided
7 Reading facilities Inadequate Inadequate Inadequate Inadequate Inadequate Inadequate
8 a. Water supply Inadequate Inadequate Adequate Inadequate Inadequate Inadequate
b. Storage of drinking water Satisfactory Satisfactory Satisfactory Not Satisfactory Satisfactory
Satisfactory
c. Drawal of drinking water Satisfactory Satisfactory Satisfactory Not Satisfactory Satisfactory
Satisfactory
a. No. of toilets 6 6 8 7 2 6
9 b. Toilet : pupil ratio 1:27 1:23 1:13 1:23 1:32 1:13
c. Maintenance Bad Bad Good Bad Good Bad

79
 a. No. of bathrooms 6 6 6 7 2 6
10 b. Bathroom : pupil ratio 1:27 1:23 1:17 1:23 1:32 1:13
c. Maintenance Bad Bad Good Bad Good Bad
Facilities for collection and
11 disposal of refuse and Adequate Adequate Adequate Adequate Adequate Adequate
garbage
a. Physical condition of the Bad Bad Good Good Bad Bad
kitchen
b. Fuel LPG LPG LPG LPG Firewood LPG
12 c. Storage of raw food Separate room Separate Separate Separate Separate Separate
room room room room room
d. Rodent infestation Absent Absent Absent Present Present Absent

13 Dining hall Absent Absent Absent Absent Absent Absent

Food handler’s hygiene Good Good Good Good Bad Good
14
(physical examination)

80
 The per capita floor area for the hostel children ranged from 6 sq.ft -

12 sq.ft in girls’ hostels which was well below the prescribed norm of

20sq.ft per child. The number of toilets provided was inadequate which

ranged from 1 for 32 girls in one hostel and 1 for13 in another hostel. Water

supply and storage of drinking water are not satisfactory. The inmates of all

the hostels are falling short of prescribed sanitary requirement of 1 sanitary

facility for 10 children. The condition of the kitchen was bad in college

hostel and two hostels have rodent infestation. Dining hall provision is

absent in all hostels and indoor lighting was found to be inadequate in two

hostels.

81
DISCUSSION

82
 Discussion
The results of the study done at Social welfare hostels, Nellore among

adolescent girls aged 11-19 years are discussed below.

Morbidity profile:-

The health problems of adolescent girls vary from place to place and

several studies conducted in India and abroad revealed that the main

morbidity conditions include infectious diseases, malnutrition, pediculosis,

dental caries, helminthiasis, and diseases of skin, and ear.

In the present study, the leading causes of morbidity were pediculosis

(83.2%), pallor (41%), dysmenorrhoea (43.6%), dental caries (28%), skin

diseases (26.4%), vitamin deficiency (21.5%), and passing worms in stools

(13.2%) and defective vision (12%).

In a study conducted by Srinivasan7 (2000), in Tirupati in 598 children

aged 6-17 years, the common morbid conditions found were skin disorders

25.7%, dental caries 21.5%, history of passing worms in stool 21.6%,

vitamin B deficiency 3.2%, ARI 1.7% and diarrohea 1.2%.The morbidity

conditions are of similar pattern but the study included boys also.

In a study conducted in urban slums of Lucknow by Singh et

al..19(2006) on 400 adolescent girls aged 10 – 19years, the various morbid

83
conditions found were inadequate oral hygiene (55.4%), pediculosis

(39.2%), cold & cough (25.8%) , lymphadenopathy (22.2%) , scabies

(16.2%) , inflamed tonsils (7.8%) and ear discharge (7%) of girls.

A study conducted by Satapathy et al.51(2008) in tribal children of

Orissa of age up to 15years, the different types of morbidities were fever

24.4%, acute respiratory infections 35.4%, goiter 14.4%, diarrhea 5%,

44.1% splenomegaly. As it is a tribal area, 14.4% suffered from malaria.

Similar study conducted by Geetha et al.24(1997) in Kaniyambadi

Block of North Arcot district of Tamil Nadu, the leading general complaints

were general fatigue, palpitations, backache and abdominal pain. The study

was conducted in rural community; girls were not educated and are more

involved in household chores leading to more musculoskelet al. disorders.

In a study conducted by Balasubramanian22 in rural Tamil Nadu,

prevalence of cold and headache was 16.62% and 10.23% respectively.

Prevalence of general morbidity increased with age and it was high among

illiterate than literates.

In a study conducted by Agarwal et al.23(1999) in Mumbai among

1,144 girls of 5–15 years age group common health problems were hygiene

related (62.2%). Dental caries and helminthiasis were common in younger

girls; pediculosis was most frequently seen in older girls, 6.6% asthma, 0.5%

cardiac diseases.

84
 In the present study, the morbidity due to skin diseases is 24.4%. In

the study by Srinivasan7, scabies accounted for 29.9%. In a study by Singh et

al.19 scabies accounted for 16.2%. In a study by Satapathy51 scabies

accounted for 15%. The high prevalence of pediculosis and scabies in

present study can be attributed to the over crowding, poor personal hygiene.

In the present study, the prevalence of dental caries is found to be

28.04%. In the study by Srinivasan dental caries was 21.5%. 13.33% of

dental caries was seen in the study conducted by Choudhary et al.32 in

adolescent girls of rural area of Varanasi. The high prevalence of dental

caries in the present study may be due to poor oral hygiene.

In the present study, the history of passing worms in stool is 13%. In

the study by Srinivasan7 the percentage of history of passing worms was

reported to be 21%. 19.4% had history of passing worms in study by

Kalamka (2001) in Nagpur.21

In the present study, 21.5% of study subjects suffered from vitamin

deficiency , among them vitamin C deficiency accounts to 11.44%. In the

study conducted by Srinivasan, the prevalence of vitamin B deficiency was

1.6%7 and another study from Western Orissa26 showed a prevalence of

28.6% of vitamin A and 42.9% vitamin B deficiency respectively.

In a study in Lucknow, the prevalence of vitamin A deficiency was

22.2%.19 When compared to other studies the vitamin deficiencies found in

85
the present study were low as they are in social welfare hostels and are

provided balanced diet when compared to Orissa and Lucknow studies

which were done in general community. The prevalence of angular

stomatitis in study conducted by Dilip kumar Das et al. in West Bengal was

15.4%.41

In the present study defective vision was 12.36%, whereas in other

studies7,19 the prevalence of defective vision was 4.7% and 4.5%

respectively. This difference may be due to inadequate indoor lighting.

Menstrual Pattern

In the present study, the mean age at menarche is 13 years. The age of

menarche among Indian girls, ranges from 11.5–14.5 years, with the current

average age being 13.5 years3.Singh et al..19, in his study found the age of

menarche to be 13.7 years. The results of two studies are comparable to each

other. In the present study dysmenorrhea is present in 43% of study subjects.

In a study conducted by Deo et al.52 dysmenorrhea was present in 31.64%. In

a study conducted by Srinivasan dysmenorrhea was noted in 3.5%. The low

prevalence of dysmenorrhea in the other studies may be due to the reason

the study subjects comprised of different age groups.

In a study by Geetha24 in rural south India, the mean age of menarche

was found to be 13.9 years and dysmenorrhea was noted in 21%.

Nutritional status
86
 In the present study, the median weight of subjects ranged from 30 ±

4.69kg to 45.5 ± 2.1kg and the median height ranged from 131 ± 6.24cm to

154.5 ± 4.06cm. These are very low when compared to NCHS standards.53

In the study conducted by Srinivasan7 the mean weights and heights of

both boys and girls were below NCHS standards, reason being both the

studies were conducted in social welfare hostels similar to present study. In a

study by Varsha Zanvar et al.54 of Marathwada region, weights, heights and

BMI were below the NCHS standards. In a study by Banerjee55 in school

children, the heights and weights were below NCHS (50th percentile) and

Indian (50th percentile) standards, 31.7% were under weight and 7.02% were

of short stature when compared to 5th and 3rd percentiles of NCHS. In the

present study 46.7% are having thinness and 13.3% are stunted. This high

prevalence of thinness and stunting may be due to inadequate food intake.

In the study conducted by Srinivasan7 in Tirupati, prevalence of

malnutrition was 78.4%.This high value may be due to lower age group.

Chabbra35 et al. noted 36.7% of malnutrition in children observation home in

Delhi.

In the study by Deshmukh30 thinness was higher in early adolescence

(57%) than in late adolescence (48.5%) whereas in my study thinness is

highly prevalent in mid adolescence (74.8%) than in early adolescence

87
(50.8%). This may be due to growth spurt. In a study conducted by Dilip

kumar das41 in West Bengal were 37.8% stunted and 14.7% were thin.

In another study by Medhi et al.29 52% of girls were stunted and 41%

were thin when compared to NHANES standards.

Studies by Geetha24 in rural south India, Raheena Begum56 in

Thiruvanathapuram reported heights and weights less than NCHS standards,

whereas Singh et al.19 in Lucknow in his study reported less than ICMR

standards.

88
Table: Comparative frequency of under nutrition among Adolescents of
different countries57

Reference study Area/ Sex Date of Under Nutrition

Population survey
Kurz, 1996 Bombay, India Both 1992-93 53.00%

Kurz, 1996 Nepal, Both 1992-93 36.00%

Kurz, 1996 Benin, Both 1992-93 23%
WestAfrica
Cookson Dadaab, Kenya Both 1998 61%
et al., 1998
Woodruff Kakuma, Both 1998 57%
et al.., 1998 Kenya
Woodruff Nepal Both 1999 34%
et al.., 1999
Mukhopadhyay.A Kolkata, India Both 2000 36.49%
et al.,
de Onis India Boys 1982-83 50.50%
et al., 2001
Venkaiah India Boys 1996-97 67%
et al., 2002
I R C, 1997 Kakuma, Boys 1997 75%
Kenya
Present Study Kolkata, India Girls 2000 30.61%
Venkaiah India Girls 1996-97 40%
et al., 2002
I R C, 1997 Kakuma, Girls 1997 55%
Kenya
Ahmed Dhaka, Girls 1995 16%
et al., 1998 Bangladesh
Present Study Nellore,A.P., Girls 2009 64.6%
India

89
 In study by Patil58 in Maharashtra according to WHO Asian Pacific BMI

criteria, 67.8% were under weight.

In the present study according to WHO BMI staging 64.6% were having

chronic energy deficiency (CED), 34.7% were normal, 0.4% obese and 0.4%

preobese. In a study by Kapil et al.59 8.1% were CED grade I, 6.65 were CED

grade II and 78.8% were CED grade III.

In a study by Raheena Begum56 in Kerala, 53% in 14 years age group and

33% in 15 years age group were having BMI <18.5.

In a study by Medhi et al.29 in adolescents of tea garden workers, median

BMI was far below NCHS median and over weight was detected in only 2

adolescents (0.33%) which is similar to the present study.

In a study by Deshmukh et al.30, CED was found to be 75.3%. This high

prevalence of CED in other studies when compared to present study may be due to

fact that they are conducted in communities and most of them have included both

boys and girls.

In the present study 49% of girls suffered from anaemia, 16.3% from mild,

29% from moderate, 4.4% from severe anaemia. The mean haemoglobin ranges

from 10.22 to 12.6gm/dl. Similar prevalence of anaemia was noted in studies by

Dilip kumar et al.41 (44.8%), Varsha Zanvar54 (46.6%), Aneja et al.43 (47%), Singh

et al.19 (56%) and Patel58 in Maharashtra (42%).

90
 High prevalence of anaemia was found in studies by Srinivasan7 (80.4%),

Chaturvedi et al.59 (73.7%), Pooja Trivedi42 (82%) and Satapathy et al. 51

(72.7%).

This high prevalence when compared to present study may be due to inadequate

iron intake and relatively high incidence of worm infestation.

In the present study the mean haemoglobin in menstruating girls (11.06 ±

1.59 gm/dl) is more than that of non-menstruating girls (10.69 ± 2.20 gm/dl), this

is similar to the study by Choudhary et al.32 who reported average haemoglobin of

menstruating girls (12.65 ± 1.3 g/dl) more than that of non-menstruating girls

(12.10 ± 1.21 g/dl).This may be attributed to awareness of girls regarding

menstrual blood loss and better intake of nutrients.

In a study by Goel et al. (2007)28 13.3% had anaemia, 84.6% anaemic

subjects had history of worm infestation, similar to the present study where

84.38% anaemic subjects had history of passing worms in stools.

Prevalence of anaemia among adolescents in India according to severity11

Study Country No of Year Anaemia prevalence (%)

91
 subjects / Mild Modera Severe Total
settings te
SWACH India 218/206 2001 SGAG*- SGAG- SGAG- SGAG-
Foundation (Haryana) SGAG/ 21.9 56.1 7.3 85.3
NSGAG NSGA NSGAG- NSGAG NSGA
rural G-17.0 61.6 -11.7 G-90.3

ICMR India 4337girls/ 2001 32.1 50.9 7.1 90.1

16 districts
(Toteja et al.)
Rajarathnam India 316, 13-19 2000 36.5 6.3 2.1 44.8
et al. (Tamil years old
Nadu) girls/rural

Kotech et al. India 2860, 12- 2000 58.0 15.1 1.6 74.7
baseline (Vadodara 19 years
survey; district) old girls
adolescent tribal, rural
girls and urban
areas
*
SGAG: School Going Adolescent Girls
NSAG: Non- School Going Adolescent Girls
Diet survey

A study of the consumption of the food items revealed that among the 13-15

years age group the intake of all nutrients was adequate except the proteins, green

leafy vegetables, other vegetables, milk, fats and eggs which were below the

recommended levels. In the 10-12 years age group, the intake of all nutrients was

adequate except milk, fats, iron, green leafy vegetables and other vegetables which

were below the actual requirement.

The diet survey results are comparable to the studies among children in

social welfare hostels of Tirupati town by Srinivasan which revealed deficit intake

92
of pulses, green leafy vegetables, milk, fats and oils, sugar, and jaggery in boys and

girls hostels which was below the recommended levels.

In a study by Swapna et al.59 in Rajasthan adolescent girls had basically a

cereal based diet. The intake of legumes, animal foods, green leafy vegetables and

other vegetables were inadequate.

In the study by Raheena Begum56 in Kerala showed deficit intake of energy,

proteins, green leafy vegetables, other vegetables and iron in a sub sample. In the

study by Varsha et.al in Marathwada54 region showed decreased intake of proteins,

energy, iron, green leafy vegetables, milk and calcium.

Environmental conditions:

The per capita floor area for the hostel children ranged from

6-12sq.ft in girls’ hostels which was well below the prescribed norm of

20sq.ft per child.60 Thus there was over crowding present in all the six hostels

which might be responsible for the high prevalence of skin disorders, pediculosis.

The number of toilets provided was inadequate which ranged from 1 for 32 girls in

one hostel and 1 for13 in another hostel. Dubey and Murdia61 (1976) in a study on

the administration of backward class hostels in Andhrapradesh found that there

was over crowding in the hostels and the sanitary facilities were grossly

inadequate.

The bad environmental conditions may also account for the high prevalence

of morbid conditions. This observation was supported by the findings of Rajashree

93
et al.62 (1994) in Kerala which revealed that owing to the environmental

deprivation, the rural coastal children exhibited poorer nutritional status in spite of

better food intake compared to non-coastal children.

94
 SUMMARY
&
CONCLUSIONS

95
 SUMMARY AND CONCLUSIONS

The following are the conclusions from the present study:

1. Majority of the girls were from rural background (83.58%).35.79% were in

middle school, 56.08% were in high school, 8.11%were in college

education. Majority of girls stayed less than five years in the hostel.

2. The major prevalent morbid conditions among girls were Pediculosis

(83.21%), Dysmenorrhea (43.6%), Dental caries (28.04%), Skin disorders

(26.4%), Vitamin deficiency (21.57%), clinical anaemia (41.14%) and

defective vision (12.36%).

3. Pediculosis, poor personal hygiene and dysmenorrhea were found to have

significance across the age groups. High morbidity was found in 11-13 year

age group. 82.3% reported illness in the past two weeks.

4. 50.36% attained menarche, majority at the age of 13 years the mean

hemoglobin of non menstruating girls was more than that of menstruating

girls.

5. The median weight of the girls ranged from 30 ± 4.69 Kg to 45.5 ± 2.10 Kg

and it was very low when compared to 50th percentile of NCHS standards.

96
 The median height of the girls ranged from 131 ± 6.24 cm to 154.50 ±

4.06cm.

6. Stunting was highest (14.7%) in 14-15 year age group. The prevalence of

thinness was 57.56%. According to WHO BMI staging 64.6% were

underweight.

7. The mean haemoglobin of the girls ranged from 10.22±0.5 to 12.6±0.11

gm/dl. In 135 subjects examined for Haemoglobin estimation, 49.6% were

found to be anaemic, among them 84.38% had the history of passing worms.

8. A study of the consumption of the food items revealed that among 13-15

years age group and 10-12 years age group, green leafy vegetables, other

vegetables, milk, fats and eggs were below the recommended levels.

9. There was over crowding in all the six hostels which might be responsible

for the high prevalence of skin disorders, pediculosis. Number of toilets

provided were inadequate.

97
RECOMMENDATIONS

98
 RECOMMENDATIONS
In view of the high prevalence and incidence of morbidity among adolescent

girls in the hostels, regular periodic medical examination and haemoglobin

estimation of inmates and facilities for treatment on the spot at school health clinic

and referral services should be organized and monitored systematically.

Special attention must be paid to the treatment and prevention of certain

diseases like skin diseases, anaemia, worm infestation and menstrual problems etc.

which are recurring in nature. In view of the high prevalence of anaemia, Iron and

Folate supplementation and Deworming must be done periodically.

In view of high prevalence of diseases associated with poor personal

hygiene, instruction to students in respect of personal hygiene, providing necessary

materials like sanitary napkins, soaps and oils etc. in kind and regular supervision

by hostel staff will go a long way in controlling these conditions.

It is very necessary to inculcate hygienic habits among adolescent girls.

Health education programmes on hygiene and common diseases have to be carried

out regularly both at school and in hostels in consultation with health authorities.

99
 The hostel menus need to be modified suitably to provide balanced diet for

intake of various dietary articles sufficient in quantity and quality.

The physical conditions of the kitchen should be improved in terms of laying

wash proof tiles and daily cleaning. Proper storage facilities are to be improved to

prevent infestation by rodents and other vermin. Separate furnished dining hall to

be provided for all the hostels.

In view of the existing overcrowding, additional living accommodation has

to be created to satisfy the norms of 20 sq.ft. for each student. Sufficient facilities

for reading and writing have to be provided in terms of space, lighting and sitting

arrangements at all hostels. So necessary provision should be made to construct

new hostel buildings with all these provisions.

Similarly additional bathrooms and toilets have to be provided and

maintained in order to improve the sanitary conditions. Hence a separate post

should be created to look after the sanitary conditions of the hostel.

100
LIMITATIONS

101
 LIMITATIONS

1. Haemoglobin estimation was carried out only on a sub sample of 135

girls and stool examination for worm infestation could not be carried out due

to logistic reasons.

2. In the present study, NCHS standards were used for comparison of mean

heights and weights as IAP standards were not available for 18 and 19 year

age groups.

3. Diet survey was conducted in only two girl’s hostels, due to constraint of

time and resources.

4. Since the hostel authorities were informed about the study, the conditions

observed with regard to the diet and environment may not reflect the true

picture.

102
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103
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112
ANNEXURES

113
 ANNEXURE – I

A STUDY ON THE HEALTH STATUS OF ADOLESCENT GIRLS

RESIDING IN SOCIAL WELFARE HOSTELS OF NELLORE CITY, A.P.

1. SOCIO DEMOGRAPHIC DATA.

1. S.no:
2. Name of the hostel:
3. Name of the student:
4. Class:
5. Age in years :
6. Residential address
7. Duration of stay in the hostel(years, months)
8. Type of family : nuclear / joint / extended
9. Total number of family members:
10. No of brothers : No of sisters:
11. Occupation of father : farmer / labourer / service / others
12.Literacy status of father : illiterate/ school educated / college educated
13. Occupation of mother : homemaker / labourer / service / others
14. Literacy status of mother : illiterate/school educated / college educated

II.PHYSICAL EXAMINATION :
15. Anthropometry : Ht(cms): Wt(kgs): BMI(kg/m²):
16. pulse rate : 18. BP:

III.GENERAL EXAMINATION :
19. Built – Thin /normal
20. Pallor,Icterus,Clubbing,Kyphosis,Lymphadenopathy,Edema -
21. Eye vision – refractive errors – present / absent
22. Signs of vitamin deficiency:
23. ENT disorders:
24.Congenital abnormalities: present/absent
25.BCG scar : present/absent
26. Habits and Behavioural problems if any :

IV. SYSTEMIC EXAMINATION:

114
 27.CVS:
28.RESPIRATORY SYSTEM:
29.PER ABDOMEN:
30.CNS:

V.INVESTIGATIONS:
31. Haemoglobin (gm/dl):
32. H/O Passing worms in the stools: present /absent

VI. PERSONAL HYGIENE:

33. Hair: dull and lusterless /healthy/clean and groomed/louse infested
34. Oral hygiene: brushing teeth daily-once/twice
34. Gums: normal / inflammation / bleeding / ulcers /others
35. Teeth: normal / caries / mottling / others
36. Nose: normal / nasal discharge / epistaxis / others
37. Bathing daily – once / twice
38. Nails: trimmed / filled with dirt
39. Washing hands with soap and water: Before eating – yes /no
After defecation – yes / no
40. Skin: normal/scabies/ pyoderma / ulcers / patches / others
41. Clothes – clean and tidy – yes / no; change daily – yes / no
42. Wearing foot wear: yes / no

VII. REPRODUCTIVE HEALTH

43. Age at menarche:
44. Menstrual cycle: regular / irregular
45. Bleeding during menstruation (days) : <3 / 3-5 / 6-7 / >7
46. Dysmenorrhoea: never / occasionally / frequently / always
47. Periods more than once a month: yes / no
48. White discharge per vaginum: never / occasionally / frequently /
always
49. Breast pain during menstruation: never / occasionally / frequently /
always
50. Pre-menstrual tension during menstruation: never /occasionally/
frequently/always

115
Menstrual hygiene:
51. Material used during menstruation: sanitary pads / new cloth / old cloth /
all
52. No. of pads used per day:
53. Method of disposal: cloth pieces reused / sanitary pads or clothes
disposed properly

VIII . HEALTH STATUS

54. Health status of the students – normal / sick
55. Any illness during the last two weeks:
H/O Diarrohea – present / absent
H/O ARI – present / absent
H/O Pyrexia present / absent
H/O Dermatitis, scabies - present / absent
56. Mode of treatment of this student – Govt.hospital / Pvt.hospital / NGO /
Home Medication.

116
 ANNEXURE – II

SCHEDULE FOR ENVIRONMENT CONDITIONS

Name of the hostel: Date of visit:

No. of children in Register:
1. Location of the hostel / distance from the road (mts) - ---------------
2. Any source of noise (Traffic) __________________Present / Absent
3. Any source of nuisance ________________Present / Absent
4. Premises of Hostels :
a) Un-necessary vegetation - Present / Absent
b) Pools of Water / Ditches - Present / Absent
c) Kept clean - Yes / No
5. Compound wall - Present / Absent
6. No. of living rooms available in the hostel ___________________
7. No. of students per each room _________________
8. Floor Area per student ______________
9. Ventilation of rooms - Good / Bad
10. No. of windows in each room ________________
11. Measurements of windows __________________
12. Tube lights / Bulbs - Present / Absent
13. Lighting - Sufficient / Non Sufficient
14. Verandah - Present / Absent
15. Furniture - Provided / Not Provided
16. Nature of Furniture -
17. Drinking water supply
a) Source of water - Sanitary well / piped water supply / Well maintained
hand pump .
b) Nature of storage of water _______________________
c) Method of drawing water-Taps / ladles- provided/Not Provided
18. Toilets provided - Yes / No
19. No. of latrines provided ___________
20. Maintenance of toilets - Good / Bad
21. Urinals Provided - Yes / No
22. No. of urinals provided - ---------------------
23. Maintenance of urinals - Good / Bad
24. No. of bathrooms provided - ----------------------

117
25. Maintenance of bathrooms - Good / Bad
26. Disposal of refuse
(Description of methods of collection and disposal)
a) Pits with in the premises
b) Thrown outside the hostel
c) Collected and burnt
d) Municipal services to collect
e) Others specify
27. Disposal of garbage ______________
28. Disposal of waste water _______________
29. Mosquito / fly breeding if any - Yes / No
30. White washing of the walls _____________________
31. Kitchen
a) Structural condition Good / Bad
b) Kept clean Yes / No
c) Rodent infestation of kitchen Present / Absent
d) Dimensions of Kitchen _________________
e) Ventilators Provided / Not Provided
f) Lighting Sufficient / Not Sufficient
g) Smoke outlet facility provided / not provided
32. Storage of food grains – separate room - Present / Absent
33. Dining Hall – provided/not provided .
34. Utensils - Steel / Brass / German Silver / Aluminium.
35. Washing method of vessels ____________________
36. If brass vessel present - Tinned / Not Tinned
37. No. of chairs and tablets in dining hall ___________________
38. Food handler’s hygiene
a) Personal hygiene - Good / Bad
b) History of passing of worms in stools -Yes / No
c) Soap and Towel provided separately- Yes / No

118
 ANNEXURE-III
OPERATIONAL DEFINITIONS USED IN THIS STUDY
Socio Demographic Factors
Illiterate - Who cannot read and write in any language were labelled as illiterate.
School educated –Subject’s education from 1st to 10th class.
College educated- Subject’s education above 10th class including post graduation,
professional.
Middle school - Subjects studying class 6-7.
High school - Subjects studying class 8-10.
Type of Family
a) Nuclear: A married couple and their children while they are still regarded as
dependent.
b) Joint family: Number of married couples and their children who live
together in the same household.
c) Three generation: This tends to be a household with representatives of
three generations.

Menstrual pattern
Menstrual cycle – Regular- subject’s having 28-30 day cycle.
Irregular - subject’s having any deviation from 28-30 day cycle.
Dysmenorrhea - the occurrence of painful cramps during menstruation.
Frequently - >5 times in one year.
Occasionally -<5 times in one year.
Always - on every menstrual cycle.
Morbidity profile
Current Morbidity status- Any morbidity present at the time of examination by
the investigator.

119
Fever-A body temperature (oral) that is higher than normal (98.4ºF) recorded by
mercury thermometer.
Exanthematous fever – Fever accompanied by different types of rash.
Scabies- A contagious skin disease caused by a parasitic mite (Sarcoptes scabiei)
and characterized by intense itching.

Pediculosis - An infestation with head louse.

Hygiene- Refers to practices associated with ensuring good health and cleanliness.

Poor personal hygiene- Refers to practices associated with: hair with lost luster,
nails not trimmed and filled with dirt, brushing teeth only once daily, teeth with
caries/mottling, swollen, inflamed / bleeding gums, skin with diseases, clothes not
changed after bath, not bathing daily, not wearing foot wear etc.
Vitamin deficiency- Is any disease caused by chronic or long-term vitamin
deficiency or caused by a defect in metabolic conversion with clinical features of
angular stomatitis, cheilosis, bitots spots, bleeding gums etc.
Defective vision - WHO criteria of visual acuity ≤6/18 in better eye detected by
Snellen chart is taken as defective vision,
Pallor - Paleness of mucosal membranes, conjunctiva, palms.
Method of haemoglobin estimation-Sahli’s haemoglobinometer
Principle- Amount of Hb can be estimated by conversion of known volume of
blood in to acid haematin by addition of dilute Hcl and subsequent calorimetric
comparison with a suitable standard.

120