Volume: III, Issue: I, January-June 2012
HOUSEHOLD ENVIRONMENTAL FACTORS AND ITS EFFECTS ON CHILD MORBIDITY IN MADHYA PRADESH
The present paper tries to understand how household environmental factors affect common child morbidity in a socio-economically backward state of Madhya Pradesh. The study utilizes the data from the third round of the National Family Health Survey(NFHS-3, 2005-06). It is found that common child morbidity like cough, fever or diarrhea is less prevalent among children living in households having better household living conditions like safe drinking water facility, good toilet facility, better socio-economic living conditions etc.
Environment can be divided into three components namely physical (water, air, housing, wastes etc.), biological (plants and animals life) and social (custom, culture, habits, occupation etc.). The term “environmental sanitation” has been defined by WHO as “the control of all those factors in man’s physical environment which exercise a deleterious effect on his physical development, health and survival”. The term environmental sanitation is being replaced by environmental health. The purpose of environmental health is to create and maintain ecological condition that will promote health and thus prevent the disease.
Improving poor environment sanitation i.e. unsafe drinking water, polluted air and soil, unhygienic disposal of human excreta and poor housing condition may protect much of the diseases in India. In developing countries disease transmission via vectors are very common. The first step in any health programme is the elimination of diseases through environmental control of those factors that are harmful to health [Datta, 2002].
Infants and young children up to the age of four years are by far the most vulnerable to health risks within the immediate family and community environment. The ability to survive the first few years of life and the quality of that survival is a function of many environmental and social stresses that impinge upon the individual child beginning during pregnancy and continuing through infancy and childhood [Audinarayana, 2005]. Infectious diseases like diarrhea, acute respiratory infection (ARI), malaria and whooping cough have been found to be the world’s leading cause of morbidity and premature death especially among the children in developing countries [Lakshmi et.al]. According to the World Health Report [WHO, 2004] 6.9 percent of death in children were attributed to respiratory infections, 2.2 percent to malarial and 2.0 percent to other childhood diseases.
Theoretically, it is widely argued that majority of the diseases can be controlled significantly under improved hygiene condition and there is no doubt that under poor hygienic condition, chances of incidence of disease is more [Kumar, 1999] Both quantity and quality of water supply are important determinants of exposure to disease. Adequate quantity is essential to permit bathing, washing, cleaning, drinking and food preparation [Mosley, 1984]. Three fifth of under five years children had diarrhea whose parents did not use any method for purification of drinking water whereas 19.1 percent under five children had diarrhea where parents were filtering with cloth or net [Chaudhari et.al., 2008]. The most common problem arises from fuel consumption inside dwelling units, weather from inadequate venting of heating and cooking devices or from burning of bio-mass fuels (firewood, charcoal, crop, residue and animal dunk) in open fires. Hundreds of millions of people suffering from diseases due to gases and pollutants from indoor may be found in high concentration areas where they are trapped inside. On the other hand, overcrowding is an evil and has health aspect as well as social aspects. Overcrowding and defective ventilation cause rise of temperature, excessive humidity and air stagnation of the room which lower the vitality of the inmates and make them more susceptible to diseases. Overcrowding helps communication of bacteria from one individual to another [Ghose, 1972]. Based on the National Family Health Survey(1992-93) data, Mishra and Retherford  noticed that ARI rate is almost one-third higher for children living in kachha houses than children living in pucca or semi-pucca houses. The rate is almost one-third higher for children living in households that use biomass fuels. Based on the NFHS-2 (1998-99) data for Andhra Pradesh and Tamil Nadu, Audinarayana  reported that the prevalence of the three child morbidity conditions (diarrhea, fever and cough) is much lower among those children living in households that have electricity as a major source of lighting followed by households that have a separate room for kitchen and some type of toilet facility. Protected drinking water and higher density in houses have also showed somewhat negative significant effect on the prevalence of fever and cough.
Majority of the studies discussed earlier, by and large, showed that housing environment affects the prevalence of morbidity among children under five years of age. However, prior research and literature also demonstrated that socio-economic characteristics of the household members (or parents) living in the household affects the housing environment and they would have a direct effect on the morbidity conditions of their children. The large part of the differentials observed appears to have been explained by educational status and working status of the mother, who is directly responsible for care and health of her offspring [Majumdar et.al., 1993 and Dhanalakshmi et.al., 1993].
In studying child mortality and morbidity, biomedical scientists give little attention to socio-economic determinants of disease except to note them as background variables and concentrates on the disease causing agents. On the contrary, social scientists seek socio-economic explanations for diseases. Both frequently tend to forget the common area, viz. the household environment which is determined by the socio-economic factors and which determines the disease causing agents. It is known that diseases occur due to imbalances caused between man and his/her environment. The agent and host factors have been identified and studied but the environmental factors of which the patient is a part remains mostly an unknown and unexplored territory. And, without the knowledge of the environment, it is difficult to prevent or control the diseases. Moreover, diseases and health are the direct outcome of a set of factors originating in the social conditions of life and behaviors of families. By and large, it is the combination of socio-economic and housing conditions in which families live, in addition to health facilities and services, which generally reduce the prevalence of deceases and determine the actual health outcomes. Identification of such factors, which may produce some differentials in morbidity pattern among children will be helpful to policy makers in their planning and intervention work to reduce child morbidity and mortality. Within this background, in this paper an attempt is made to examine whether housing environmental factors would have any influence on the three common child morbidity conditions viz., diarrhoea, fever and cough. Attempt is also made to examine such effects by controlling the (in the presence of) selected socio-economic characteristics of parents and households.
Data and Methods
The data required for the present study were drawn from the National Family Health Survey-3 (NFHS-3,2005-06) for the state of Madhya Pradesh. The survey was conducted in Madhya Pradesh during April 2006 to August 2006. Information for the selected variables has been matched from household file and children’s file. The total no of children born during last five years preceding the survey i.e. children of age under five years are considered for analysis. A sample of 3420 children of Madhya Pradesh is taken into consideration for this analysis.
Mothers of children born during the five years preceding the survey were asked if their children had suffered from either cough, fever or diarrhea during the two weeks preceding the survey. Accuracy of all these measures is affected by the reliability of mother’s recall of events when the disease episode occurred. This morbidity information is based on mother's perception of illness without validation by medical personals.
Questions on the type of toilet facility, type of fuel used for cooking, source of drinking water, methods to purify water, type of house, number of person in household, number of sleeping rooms and whether there is separate room for kitchen asked in NFHS questionnaire is used for the present study. Questions on mother’s education, residence and working status have also been used. Piped water, hand pump and protected well have been classified as source safe water and rest are considered as unsafe. Wood, straw/grass, crop and animal dung have been considered under “others” category.
The analysis is done at three stages. Firstly the prevalence rate of diarrhea, fever and cough among the sample children have been computed based on the formula of prevalence rate of morbidity. At the second stage, the differentials in the prevalence rate of the three morbidity under consideration have been computed for each disease separately across the selected socio-economic characteristics of the parents and the household environment factors. Finally, the determinants of different child morbidity conditions have been examined with the help of logistic regretion analysis.
Prevalence Rate of Morbidity
In the present context, period prevalence rates have been computed. Such rates would measure the frequency of all current cases (old and new) existing during a defined period of time expressed in relation to a defined population. It includes cases arising before but extending into or through the period as well as those cases arising during that period.
Number of persons who are sick some
Period Prevalence time during a defined period
rate (persons) = ------------------------------------------------------------ * 100
Average number of persons exposed
to the risk during that defined period
Table1. Prevalence Rate of Diarrhea, Fever and Cough among children up to age five in Madhya Pradesh(NFHS-3)
The prevalence rate of diarrhea, fever and cough among the children(up to age five) of Madhya Pradesh is presented in table 1. Of the three diseases, the prevalence rate of cough is found to be the highest(14%) among the children under age five followed by fever(13%) and diarrhea(12%). The data reveals that cough is the most frequently occurring disease among the children as they are most vulnerable to this kind of disease.
Results and Discussion
Distribution of Household Characteristics in Madhya Pradesh
Table 2 shows that in the state of Madhya Pradesh almost 72 percent households used safe sources of drinking water. Sanitary facility is an important factor which influence on the health of household members. The table reveals that about four fifth of the households have no facility for toilet and use open spaces for toilet while only 1.2%used pit latrines. The several types of fuels are used for cooking in Madhya Pradesh. Only 12 percent households used electricity/LPG/biogas, 1.2% used kerosene/coal/charcoal and the rest(87 %) used bio-mass, wood or crop residues. Almost 60 percent households have no separate room for kitchen. Regarding type of house construction, 26% are kachha, 53% are semi-pucca and 21% are pucac households. Wealth is a important determinant for household amenities in Madhya Pradesh where 42%households belong to poorest wealth quintile, 25% belong to poorer wealth quintile, 13% belong to middle wealth quintile, 12% belong to richer wealth quintile and only 8% belong to richest wealth quintile.
Differential in Child Morbidity Conditions
Differential in Diarrhoea
Diarrhea is a very common disease among the children under the age of five years in India and Madhya Pradesh is no exception to it. It is a water borne disease and mostly occurs due to the drinking of contaminated water. The data on differentials in child morbidity conditions on three diseases(diarrhea, cough and fever) by background characteristics is presented in table 3.The socio-economic conditions as well as the household living environment influences the incidence of diarrhea cases.Contrary to the expectation, prevalence of diarrhea is more among children living in pucca houses closely followed by semi-pucca houses and rest in kachha houses. It is also less in moderately crowed houses and households which have a separate room for kitchen. As expected, diarrhea is less prevalent among children living in households for which source of drinking water is safe and households where there is some type of toilet facility. Across all the socio-economic variables, prevalence of diarrhea is more among the children living in urban areas and whose mothers are working. It is also surprising to see that prevalence of diarrhea is more among those whose mothers have some education and belong to richer wealth quintile as higher education of the mother and better economic condition of the household is expected to reduce prevalence of diarrhea.
Differential in Fever
Similarly fever is also a very common disease among the children under five years of age in India. The incidence of fever among the children varies as per the household living environment and other socio-economic characteristics of the household. Table 3 presents information on incidence of fever among children below five years of age in Madhya Pradesh by background characteristics. The prevalence of fever is more among children living in semi-pucca houses and kachha houses. It is also high where density of household is high, no separate room is used as a kitchen, where source of drinking water is unsafe, toilet facility is pit and bio-mass, wood or crop residues is used for cooking than their counterparts. Across the socio-economic variables, prevalence of fever is more among the children living in rural areas, whose mothers are working and children who belong to poorer wealth quintile group.
Differential in Cough
Cough and cold is a very common disease among the children below five years of age in India. This is one of the important causes of morbidity and mortality among the children in the developing countries in general and India in particular. The information on incidence of cough among the children by background information for Madhya Pradesh is presented in table 3.The prevalence of cough is more among children living in semi-pucca houses, no separate room is used as a kitchen, where source of drinking water is unsafe and kerosene/coal/charcoal is used for cooking followed by bio-mass, wood or crop residues. Across the socio-economic variables prevalence of cough is more among the children living in rural areas, whose mothers are working and children who belonging to middle wealth quintile followed by poorest and rest for children belonging to richest wealth quintile.
Determinants of Child Morbidity Conditions
As noted earlier, in order to find out the principal determinants of child morbidity conditions under consideration, it is proposed here to adopt binary logistic regression analysis. This has been carried out by using two different models; in the first model, only variables of household living conditions have been regressed with the morbidity conditions and in the second model, selected socio-economic variables have also been included along with the household variables. For the purpose of these analyses, the dependant variables viz., incidence of diarrhea, fever and cough have been considered as dichotomous, i.e., giving a value of ‘0’ for absence of a particular disease(no disease ) and ‘1’ for the presence(yes).
Results of Logistic Regression Analysis for Diarrhoea
Table 4 contains information on results of logistic regression analysis of prevalence of diarrhoea, fever and cough with other socio-economic and household characteristics. Logistic regression results on diarrhoea of children reveal that among the housing environment factors, only three have turned out to be comparatively significant in showing their net effects on prevalence of diarrhoea. For instance, children living in the pucca houses are 73% more likely to have diarrhoea than the children living in kachha houses. It may be due to improper ventilation and lack of cleaning in the pucca houses. The odds of diarrhoea are high for those children who live in households which have a pit toilet facility than those who didn’t have such a facility. Prevalence of diarrhoea is more among the children living in households where kerosene/coal/charcoal is used as a cooking fuel than the households where bio-mass, wood or crop residues is used for cooking. Prevalence of diarrhea is more in crowed houses though it is not statistically significant. It is found that in the presence of socio-economic characteristics, the net effect of household environment factors is almost same. On the other hand, the odds of experiencing diarrhoea are less for the children whose mother are working than the non working mother but the difference is not significant and high. Among wealth quintile, children belonging to richest wealth quintile is 61 percent less likely to have diarrhea than the children belonging to poorest wealth quintile. It is quite obvious that those households having higher economic development have experienced less child morbidity due to diarrhea than those having lower economic development.
Results of Logistic Regression Analysis for Fever
The information pertaining to results of logistic regression analysis for fever is presented in table 4. A few household environment variables have exhibited somewhat significant net effects on the odds of children suffering from fever in which two results are in the expected direction and the other one is contrary to the expectation. For instance, it is interesting to note that children who are using water from safe source are 24%less likely to have fever than the children who are using water from unsafe source. Odds of fever is comparatively low among those who belong to the households where kerosene/coal/charcoal is used as cooking fuel than those who use bio-mass, wood or crop residues. Contrary to the expectation, 54% more children suffer from fever in those households where flush is used for toilet than the households in which no such type of facility is available. It is noted that even in the presence of socio-economic factors, the net effects remained almost the same. Moreover, contrary to the expectation, the likelihood of children suffering from fever is observed to be significantly higher among those whose mothers have completed secondary school education than their illiterate counterparts.
Results of Logistic Regression Analysis for Cough
Table 4 also contains information on results of binary logistic regression analysis for the children who had cough. Logistic regression results for cough among the children showed that among the household environmental factors only two have turned out to be comparatively significant in showing their net effects. Odds of having cough is higher among the children who live in the semi-pucca houses than the children living in kachha houses. The prevalence of cough is 31% less in the household where electricity/LPG/biogas is used as a cooking fuel than the households where the bio-mass, wood or crop residues are used as a fuel. It is found that in the presence of socio-economic characteristics, the net effect of type of house on the likelihood of cough among children has the same effect. But the effect of type of cooking fuel on prevalence of cough is found to be insignificant. Another important finding noticed here is that education of mother do not influence the prevalence of cough in the expected direction. The likelihood of children suffering from cough is higher for children whose mothers are literate than the children whose mothers are illiterate. A possible explanation may be that illiterate mothers are less likely to report incidences of cough than the more educated mothers. The prevalence of having cough is negatively linked with wealth. The likelihood of having cough is 29% less for the children belonging to poorer wealth quintile, 39% less for the children belonging to middle wealth quintile,61 percent less for the children belonging to richer wealth quintile and 74%less for the children belonging to richest wealth quintile.
Summary and Conclusion
Though it is difficult to find out the relative effect of household environmental factors on child morbidity as one has to consider other different aspects of environment. Based on the findings of the present paper some of the following conclusions may be drawn. With a few exceptions, by and large, the bi-variate results support most of the theoretical considerations with regard to the associations between household environmental factors and prevalence rates of diarrhoea, fever and cough among children. The results based on the logistic regression analysis highlight that only two to three household environmental factors turn out to have significant net effects on the prevalence of different morbidity. Children living in the pucca houses are more likely to have diarrhoea than the children living in kachha houses. The odds of diarrhoea are high for those children who live in households which have a pit toilet facility than those who didn’t have such a facility. Prevalence of diarrhoea is more among the children living in households where kerosene/coal/charcoal is used as a cooking fuel than those households where bio-mass, wood or crop residues is used for cooking. Among wealth quintile, children belonging to richest wealth quintile is 61% less likely to have diarrhoea than the children belonging to poorest wealth quintile. It is interesting to note that children who are using water from safe source are less likely to have fever than the children who are using water from unsafe source. Odds of fever among the children is comparatively low among those who belong to the households where kerosene/coal/charcoal is used as cooking fuel than those who use bio-mass, wood or crop residues. Contrary to the expectation, more children suffer from fever in those households where flush toilet is used than those households in which no such type of facility is available. Odds of having cough is higher among the children who live in the semi-pucca houses than the children living in kachha houses. The prevalence of cough is less in the households where electricity/LPG/biogas is used as a cooking fuel than the households where the bio-mass, wood or crop residues are used as a fuel. The prevalence of having cough is negatively linked with wealth. Another important finding noticed here is that education of mother does not influence morbidity of the children along the expected direction. The likelihood of children suffering from morbidity is higher among children whose mothers are literate than the children whose mothers are illiterate.
In the light of the above findings some conclusions may drawn which have policy implications. All the three common diseases among children namely diarrhea, fever and cough are preventable. First of all, people in general and parents in particular need to be informed and educated about the detrimental effects of household living conditions on child health and the need for improvement of the housing environment, especially, keeping up a separate room or space for kitchen outside the living room, drinking protected drinking water and constructing houses with more number of living rooms. Policy also be formulated to discourage use of fuels producing indoor air pollution which has negative effects on the health of the household members in general and children in particular. Policies should be formulated to construct better quality houses with better living conditions, provisions for safe drinking water through taps and flush toilet facilities which will improve the health of the children and reduce the incidence of diseases and death among the children. Improving overall socio-economic conditions of the people in general and that of women in particular is also essential in order to reduce child morbidity and mortality in Madhya Pradesh.