HOMEMAKERS FROM UPPER SOCIOECONOMIC JOINT FAMILIES HAVING EARLIER MALE CHILD WOULD BE THE BEST PREDICTORS FOR ADEQUATE KNOWLEDGE AND PRACTICE REGARDING MANAGEMENT OF ARI AND DIARRHOEA AMONG UNDER-FIVE CHILDREN IN URBAN SLUM, KOLKATA.

Dr. Md.Tousifullah 1 , Dr.Arup Chakraborty 2 and Dr. Arista Lahiri 3 . 1. Junior Resident, Medical College, Kolkata. 2. Assistant Professor, Department of Community Medicine, Medical College, Kolkata. 3. Junior Resident, Department of Community Medicine, Medical College, Kolkata. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 5 (6), 432-439 433 (Gottipati S., 2012). Acute Respiratory Infections and Diarrhoea are considered to be the major causes of mortality and morbidity in under-five in India and world-wide. India tops in global pneumonia deaths of under-five children with 3.97 lakhs reported in 2010 (PTI, 2012). On the other hand data from the Global Enteric Multicentre Study (GEMS) shows diarrhoeal disease, which is responsible for one in every ten deaths during the first five years of life worldwide, has the highest rate of incidence in India compared to other countries (Jha D.N., 2013). Most of these deaths are due to dehydration and mismanagement or delayed management of the disease. Most of the disease episodes can be treated at home by mothers. The slums owing to their environmental features report a steady proportion of these cases. Therefore knowledge, attitude regarding the mentioned diseases and practices as well, of the mothers of the under-five children living in a slum area even more important to note in order to decrease both mortality and the morbidity burden.
Our study was aimed to explore the knowledge, attitude and practice regarding acute respiratory infections and diarrhoea among mothers of under-five children and to find the association between the level of knowledge and various factors affecting it.
It is well established that knowledge of the primary care givers are very important to prevent morbidity and mortality due to these primary killer diseases in child hood. Several studies have been done to assess level of awareness of primary care givers in relation to these diseases. A study by Shah MS, Ahmad A et al. (2012) in Aligarh highlighted that the mothers' knowledge regarding to those diseases was not adequate. Another study done by Gupta N, Jain SK et al. (2007) in a Delhi slum concluded that though the care givers were aware about the danger signs of ARI but still correct practices of home based management e.g. use of ORS, continued feeding etc. were deficient. Almost a similar study performed by Khamgaonkar MB, Kulkarni AP et al. (1999) revealed the lack of awareness regarding home management of diarrhoea and symptoms of pneumonia in around half of the mothers in a community.

Methodology:-
A Cross-sectional study among mothers of under-five children was conducted in the month of August& September, 2014 in a densely populated urban slum, situated within the limits of Kolkata Municipal Corporation (KMC), West Bengal.
Mothers, who gave consent and whose family were permanent residents of the area, having at least one living under five child at the time of interview was included in the study with the exclusion of mothers who were absent during the day of data collection.
According to a previous study (Gupta N, Jain SK et al., 2007) awareness of at least two danger signs present, was known by 34% mothers, the sample size was calculated 98 by putting a design effect of 1.1 with allowable error 10% of prevalence with the help of a cluster design. The particular area was well communicated with the heart of the city. There were 9 passage-lanes across the area and houses were built on both sides of them. With cluster sampling design, houses on either side of each passage-lane was designated as a cluster. Now from each of these clusters we took 98/9 ≈ 11 number of houses and one mother from each house. Study participants were chosen beginning with the houses on the left side of a passage-lane starting from the first house and proceeding along the passage-lane and then the houses on the right side in a reverse order. In each of the 9 clusters consecutive houses having the mother of under five children (meeting the inclusion criteria) were taken until we have reached 11number of mothers in that particular cluster.
A predesigned pretested semi-structured survey schedule was prepared based on World Health Organization (WHO) CDD / ARI core household survey questionnaire (World Health Organization, 1994) and was used for data collection after obtaining ethical clearance from the Institutional Ethics Committee. The collected data was entered in Microsoft Excel 2007 version and subsequently analysed in Statistical Packages for Social Sciences (SPSS) version 20.
The participant mothers received certain scores as per their responses to the questions. These scores have been used to quantify knowledge and attitude. The participants who scored more than or equal to the mean score (for knowledge) have been categorized into higher knowledge group and the rest poor knowledge group. The different socio-demographic factors which might have influenced the knowledge were considered for tests of significance analysis keeping the level of knowledge as dependent variable.

Results and Discussion:-
The present study was conducted by interviewing 101 study participants using a predesigned pretested schedule. The mean age of mothers was found to be 28.07 years (SD 5.13 years). Mean age of marriage of the participants was 20.68 years (SD 3.48 years) which was comparable to national figure of 21.2years ("Population composition -Census of India"). Majority belonged to a nuclear family (64.4 %) which was consistent with the fact that study was done in urban slum. Mean age of last child was 26.9 months (SD 17.15 months). Majority (81.2%) of the last-born children were delivered in hospital. Improved awareness of the benefits of institutional delivery along with the facility of being near to a major Government Medical College and Hospital was probably responsible for the results. Mean education of the participating mothers was 5 th standard with the range varying from illiterate to graduate. This might be the reflection of their poor economic background which compelled them to leave school early. 40/101 mothers (39.6%) were illiterate. The result was almost consistent with national literacy rate for females ("Literacy rate India", 2011). Majority of the mothers were home-makers (84.2%) with only 15.8% having any relative attached to a health-care. Majority of the people were from upper lower (46.5%) and upper middle (36.6%) socioeconomic category with no one belonged to lowest category of the Modified Kuppuswamy scale. Majority of the mothers (77.2%) had only one under five children at the time of the study. (TABLE 1) Of the 101 children in this study 22 children suffered from diarrhoea, 36 children with illnesses with cough within last two weeks immediately before study. This may be due to the seasonal variation as it was rainy season during the period of study.70 episodes of respiratory symptoms (36 episodes from illnesses with cough, 31 were from blocked/ runny nose and 3 from sore throat) and 9 episodes of fast breathing were complained by the mothers (TABLE  2).Similar finding was documented in the study done by Gupta N, Jain SK et al. (2007) in a Delhi slum, which showed only 8 (4%) had fast breathing.
Out of the 9 episodes of fast breathing 4 mothers thought that illness was due to problem in chest. Mothers sought outside care in cases of 8 episodes. (TABLE 3).39.6 % of mothers said that a child with cough should be taken for health care when fever developed, 21.8% said if the child did not get better and 16.8% said that if the child had develop fast breathing (TABLE 4). Though majority of mothers were aware about the warning signs of ARI, however in a similar study performed by Khamgaonkar MB, Kulkarni AP et al. (1999) in an urban slum in Nanded city, found that 50.4% of the mothers did not know a single symptom of pneumonia. In the present study, among children with cough, 83.3 % of mother sought outside care, among which majority sought care from Government Hospital or Government Health Centre or private physician (TABLES 3 & 4), determined a good practice. Almost similar findings was explored by Gupta N, Jain SK et al. (2007) in a Delhi slum that, 80% of mothers were aware about one or more danger signs of pneumonia and 80% of them had sought outside treatment.
In the present study, most of the respondent (32.7%) correctly said that they would take their child with diarrhoea to health care facility if they had many watery stools, which was followed by a response from 21% that suffering from fever along with diarrhoea was the need for shouting the help from a health care. Remarkably very few (6.9%) knew that outside care should seek when child stopped eating or drinking (TABLE 5). In a similar study done by Shah MS, Ahmad A et al. (2012) in Aligarh showed, life-threatening symptoms which mothers knew as a reason for seeking medical help were watery stool (85%) and repeated vomiting (54%). Study in a Delhi slum (Gupta N, Jain SK et al., 2007) revealed awareness of at least two danger signs as a requirement for seeking outside help was present in 34% mother.
The present study found that 48.5% of mother correctly knew to give more fluids when their child had diarrhoea where as 51.4% mother said they would give less or same amount of fluid, which was wrong knowledge. On the contrary, 62.5% of mothers correctly said they would give their child more or same amount of food when they had diarrhoea. Out of the 22 children who had diarrhoea, outside care was sought (either Government Hospital or Government Health Centre or private physician) in majority cases (86.4%). (TABLE 5).In a previous study done by Gupta  In the present study, 86.4 % children of those who had diarrhoea were managed by Oral Rehydration Salt (ORS) and Recommended Home-based Fluid (RHF) during diarrhoeal episodes. The home based fluid given was either saltsugar solution or rice water or dal water, which was as per recommended guideline for home based management of diarrhoea by World Health Organization (2005).Almost all the ORS and RHF were advised by Government Hospital or Government Health Centre or private physician. 66.66% of the mothers prepared ORS properly. (TABLE  5) Finally, the study looked for the association of different socio demographic factors with the level of knowledge. It was supposed that advance maternal age would influence the knowledge but there was no statistical significant association found between the two. Mothers of U-5 children belonged to joint families had 1.7 times higher knowledge than mother who belonged to nuclear families. This was probably due to the fact that, in the joint family there was higher scope to get the information from different peers as they stay in the same household. It was supposed that mothers who had more than one child should have higher knowledge due to the experience gathered from child rearing but there was no such statistical significant association found. Hospital delivery of mothers did not found to be an influencing factor in developing knowledge over the home deliveries. This revealed the fact that mothers were not getting adequate health education from the hospital after delivery or at the time of discharge or it might not had been reinforced from time to time. There was no statistical association found between higher education of mothers and the level of knowledge. It was assumed that working mothers would have higher knowledge than their home-maker counter-part as it would possible for the working mothers to get the information by virtue of their more exposure to external environment as well as work places, but statistically significant association was not established. In our study the odds ratio calculated were more in favour of mothers who were home-makers (OR 1.333). This may be a spurious association due to very less representation (15.8%) of working mothers in the study. Mothers of under-five children whose relatives were working in any health facilities, their level of knowledge was 1.15 times higher than the others. Mothers those had a previous male child, had 1.5 times higher knowledge than who had prior female child. Socio economic status also did not have any statistical significant association in acquiring knowledge though upper socio economic status had 1.2 times more knowledge than the lower socio economic group. (TABLE 6)

Conclusions:-
The study concluded with the facts that, though majority of the mothers were home-makers, belonged to upperlower socio-economic category with an average educational qualification of 5 th standard, yet most of them were aware about the danger signs of serious respiratory illness like pneumonia and diarrhoea and used to seek outside care from Government Hospital or Government Health Centre or private physician if required. It was also observed that, majority of mothers had lack of knowledge on home based fluid management during diarrhoea. The incorrect knowledge about fluid management was reflected upon their practice as during the attacks of diarrhoea majority of children drank less fluid. One third of study mothers prepared ORS wrongly. So, based on the findings continuous health education may be reinforced in future in that slum area and post health education evaluation of knowledge attitude and practice also can be compared.