indian council of medical research - Pondicherry University DSpace ...

A Case Study of the Health, Education and Social Status
af School Age Children with Empharir on the
Girl Child in South India
THESIS SUBMITTED TO
PONDICHERRY UNIVERSITY
FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY IN EPIDEMIOLOGY
BY
IIH. SHANTI ANAKTIIAKRIHHSAS, M.D. (PEDIATRICS).. D.C.H.
DR. Y. Pa PAXI, M.D., Ph.D. (EPID.).
DEPUTY DIRECTOR AND HEAD
DIVISION OF CLINICAL EPIDEMIOLOGY AND CHEMOTHERAPY
VECTOR CONTROL RESEARCHCENTRE
(INDIAN COUNCIL OF MEDICAL RESEARCH)
PONDICHERRY, INDIA
APRIL 1098

VECTOR CONTROL RES(EARCH CENTRE
(Indian Council ol Medicel Research)
lndira Nsgar, Pondtoheny - BO5 W6.
Telephone : 1 72784,7231,72397 Fax : h / 72422,72Q41
Telepram.W I Mosquilo E-Mail : md@icmwcrc.ren.nic.in
This is to mfhy mat the thesls emad .A cw study w me nm, EM^ And sod#
status W School Age Chlldm WA Emphds On me Dlrl ChNd lk Soum hae" submated
by Dr. ShnY rCDnihlklhnm is a booaIWs r& of resecvch wwk done by the c6nd&te
durlng the period of study under my supervision.
Dr. Shenti AnanMsMshnan Is om of Mpse m dinklens rr3rc has shorn, keen Wen,& h cwighsl
research wc& re- lo chical epmmblcgy wW a social mkwmx. Her ertlhusiasm en0
commXmerl h Ibrmuls(lng, &- end h n the ahrdy, ~ eapmms ~ lo lm new
emmwnmic researoh mahods and use ofcomputers, petb~etienn, and p srsem lo psm data
fromandIvea,haveconblbuledto t he~ofherressmh~.
The thesis has not M the basis for the e W to the cano'idsh, of any Degee, Dipkme,
Associsteship, FeHowship or other hiWtWe.
Piaca: Pondicheny
DiviDton of Clinical Epidsmiology andchemotherapy
P
WORLD HEALTH ORC1ANlZATIOR
Coliabontlng Cant" for Ru~roh
d Tmolnp n
Integrated Method. ol Vector CoNml

ACKNOWLEDGMENT
"No man is an island, entire of itserf;.
every man is a piem of the continent,
apart of the main'!
(John Donne)
Any work, be it ever so humble, awes its completion to the unstinted help, advice and
cooperatiotr recerved from many persons throughout its gestation. I hereby wish to
acbowledge, with heartfelt gratitude and profound thanks, their contribution to the
preparation andsubmission of this manuscript and to the work that was its raison dItre.
Late Dr. Vjay Dan&, fotmer drrector of the VCRC, Pondicheny for redly accepting
me as a doctoral student in the VCRC and for his understandrng and bnhess in the
formative phases of the study and without whose help the project would not have bccn
initiated;
Dr. S.P. Pani, Deputy Director and Head, Division of Clinical Epidemrology VCRC, my
supervisor wrthout whose efforts nothing would have been possible. I have learnt a lot
regarding research methodology and the mtricacies of clinical epidemiolog~cal methoak
from him. His constant encouragement and well thought out comments have inspired me
towardr completion of the goal. It was a pleasure working with him. I will for ever
remember his patient and meticulous grndance;
Dr. P.K. Das, Director, VCRC for constant and continued encouragement,
ahrnrstrative and ir~stitutronal support;
Dr. P. Nalini, Professor of pedairics, JIPMER, my co-supervisor for her words of
adwce and encouragement during dg$jcult trmes;
Dr. M. Dhanabalan. Professor and Head, Department of Preventrve arrd Socral
Medicine atrd Dr. S. Srinivnsan, Professor and Head, Deparlmetrt of Pedratrrcs
JlPMm members ofthe Doctoral commrttee, for their critrcal comments;
Dr. Ajit Sahai and Dr. K.A. Narayanan, Professors of Preventive and Socral Medicore,
JIPMER, for their invaluable suggestions in designing the study;
Dr. K. D. Ramaiah atrd Mr. N. Ramu, VCRC, for their help m making me understartd
the rtrtncacies ofethtiographrc study and costing;
Mr. P. Vanamail and Ms. A. Srividya, VCRC, for help in choosing the appropale
statistical test for the analyses;

Mr. R Dhanagopal and Mr. A. Elango ,VCRC, for introducing me to the use of
computers m recording and analyses of data; *
Dr. S Mohodcwn and Dr. R Vihnu Bhot, Professors of pediatric^, JIPm, for
valuable suggestions and important references;
Dr. Sushi1 Pani, ophthalmologist, Dr. P. Yinidlr, Senior Resident, Mz JIPMER, Dm.
Girish, Dinokw and Sridhw, Residents, Department of Pediamcs, JIPMER, for their
support:
Dr. (Mrs..) Sodhano Sivam, Senior resident, Department of Preventive and Socral
Medicine, JIPMER, for help m designing the questionnaire;
Dr. Subhmyan, Medical oflcer, PHC Kedar and Dr. Bo/och~&on of the School
Health Cell, Pondicherry, for their cooperation atxi mdng available the recordsfor the
study:
My firerids Mrs. N. Vijoyalcrkshmi for going through the draj manuscript and Mrs.
Munowar Hobeeb for help irr proofreadmg;
Mr. S. Perumolfor meNnrlous typing of the manuscript.
Finally I wish to thank all the people of KeJar Village, the Kedar School Authorities and
the wonderful chil&en of Kedar for ,heir sewess atxi enthusiastic cooperation
throughout the study.
Lj,)L,l.Lc~2 L{,~,< h~,&.'{h (
(Shanti Ananthakrishnan)

CONTENTS
CHAPTER
PAQE No.
I. INTRODUCTION
2. AIMS AND OBJECTIVES
3. OVERVIEW OF STUDY DESIGN
4. STUDY AREA AND DEMOGRAPHY
Tables 8. Figures
5. HEALTH STATUS OF SCHOOL AGE CHILDREN
5.1 INTRODUCTION
5.2 REVIEW OF LITERATURE
5.3 METHODOLOGY
5.4 RESULTS
5.5 DISCUSSION
Tables 8 Figures
6. EDUCATION STATUS OF SCHOOL AGE CHILDREN
6.1 INTRODUCTION
6.2 REVIEW OF LITERATURE
6.3 METHODOLOGY
6.4 RESULTS
6.5 DISCUSSION
Tables 8 Figures
7. SOCIAL STATUS OF SCHOOL AGE CHILDREN
7.1 INTRODUCTION
7.2 REVIEW OF LITERATURE
7.3 METHODOLOGY
7.4 RESULTS
7.5 DISCUSSION
Tables P. Figures
8. SUMMARY AND CONCLUSIONS
8.1 SUMMARY
8.2 CONCLUSIONS
9. ,RECOMMENDATIONS
8.1 HEALTH
8.2 EDUCATION
9.3 SOCIAL
8.4 FUTURE RESEARCH
10. BIBLIOGRAPHY
11. APPENDIX
i-xviii

Introduction

INTRODUCTION
The children of today are the generation of tomorrow. Children pass through various
stages in their development. Starting as an embryo in the womb they go through the
fetus, newborn, infant, toddler, preschool, school, adolescent, young adult stages
before finally becoming mature adults. We may broadly recognize 4 phases of child
growth: (i) intra uterine phase and early infancy, conception to 6 months after birth; (ii)
late infancy and early childhood. 6 months to 5 years ; (iii) primary school age, 5-12
years; and (iv) adolescence, 12-18 years; (Gopalan,1993). Each one of these phases
is important and has to be given special attention in order that the child has optimum
growth and development.
In research studies and national programs ir the past, emphasis was laid pnmarily on
one phase or the other to the relative neglect of other phases. There was a time in the
fiflies when school meal programs and school health sewices commanded
considerable attention. The interest in this area of development waned in the sixties
with the emphasis shifting to the preschool children, because the worst forms of
malnutrition and illnesses were seen in them (Gopalan,1993). Therefore, adequate
altention by the various maternal and child health services was given and is still being
given to the child from the time of conception to the age of 6 years. The success of
these services is reflected in the declining infant and child mortality rates. The infant
mortality rate (IMR) In India has fallen from 14711,000 in 1951 to 7911,000 in 1992
(Bhargava.1991; Anonymous,l995).The child mortality rate has fallen from 85.811,000
in 1972 to 33.411,000 in 1992 (Bhargava,l991; Anonymous,l995). A s~m~lar trend has

een observed in many parts of the world (Bundy and Guyatt,1995).
Sample
Registration System (SRS) data indicate that under five mortality rate is decl~nlng at a
rate of 3.0% per annum (Bodhanker and Shasikala,1995). Later in life, attention is
again focused on them as adolescents end young adults because they enter an
economically productive phase and are faced with many behavior problems. The
Important school age period sandwiched between these two phases, has not
received the due attention from parents, teachers and health professionals. This is
possibly due to its relative freedom from serious illnesses and signif~cant behavior
problems. There Is a dearth of community level information on the needs of the school
age children and identification of areas that require attention of everyone concerned
(Bundy and Guyatt,l995).
School age is very important in the development of an individual because ~t is during
this phase, the foundation for future physical end behavior pattern is la~d. These in turn
determine the individual's health and also his ultimate economic and social potentials.
There is no uniformity in the definition of school age. Whereas primary school age is
between 5 and 12 years (Gopalan,1993), school age broadly spans the period between
6 and 14 years (UNICEF,1990) or 5-14 years of age (Bundy and Guyatt,1995). In ind~a,
a child must have completed 5 years before entering the flrst standard and there are
10 years of schooling. Therefore logically the school age is between 5 and 15 years of
age.
During these crucial 10 years, the inputs laid in the preschool years for
intellectual, cognitive, social, emotional, physical and language development are
nurtured and the individual is helped to blossom to his full potential and become an
economically productive and socially Iw-nonious member of the community. In thls

phase, there is maximum educational and vocational input. The specific needs are
health, education and social well being; one cannot be divorced fmm the other.
A vast majority of these children have sub-standard health and consequently fall to
attain optimally healthy and productive adulthood. There are about 1,000 million school
children in the world today (Bundy and Guyatt, 1995). The problems encountered in this
stage are myriad. Using disability adjusted life years (DALY) metric, it has been
estimated that school age children suffer 11.0% of the total global burden of disease
and 97.0% of this burden is borne by children of the developing world. Tuberculosis,
intestinal helminths, injuries, respiratory disease,
malaria, Chagas disease,
Schistosomiasis, neuropsychiatric disorders, and acquired immunodeficiency syndrome
(AIDS) and other sexually transmitted diseases are some of the other common causes
of DALY loss (Bundy and Guyatt,1996). It was also estimated that 40.0% of the 1.000
million school age children are infected with intestinal worms (Sanoli et a1.,1996). In
addition, there are problems related to specific types of school age children like street
children, working children and handicapped children. These form specific problems
requiring independent studies and some of their issues have been addressed earlier
(Weale and Bradshaw,l980; Raju,1989; Banerjee, 1990; Banerjee,1992).
In our country, there are about 270 million school children forming 27.0% of the
population (Anonymous,l994). Health surveys in Indian schools indicate that morbidity
and mortality rates of children are among the highest in the world (Mahajan,l992).
Morbidity of school children has been studied in small surveys in many parts of the
country and most of these surveys have yielded more or less similar findings: the
general prevalence of morbidity being malnutrition (10.0%-98.0%), dental ailments

(4.0%-70.0%), won infestations (2.0%-30.0%), skin diseases (5.0%-10.0%), eye
diseases (4.0%-8.0%), and anemia (4.0%-15.0%) (Gupta et a1.,1973; Bansal et
ah, 1973; Tragler,lQ81; Rao et a1.,1984; Ananthakrishnan et a1.,1987; Gupta. 1989,
Bhattacharya and Tandon,1992; Khanna et a1.,1995). An evaluation of the School
Health Program all over the country showed that 24.0Y0 of the school children medically
examined had some disease or defect (Mahajan.1992). It has also been observed that
school children suffer from learning disabilibes (Agawal,l991). Due to the high degree
of morbidity and learning disabilities seen among children of school age, heavy
investment in primary education program in our country has not had the desired results
(Gopalan.1993).
School children properly motivated and educated can become useful agents of change
in the community and also valuable adjuncts to community development programs.
Therefore, one of the important needs of the hour is to improve the educational status
of school age children by enhancing enrollment and school attendance. Although over
90.0% of children in the developing world enroll in school, only about 50.0% reach
grade V (UNICEF, 1994). A matter of concern is the high dropout rate and low level of
achievement of those who continue in schools. The highest priority in education is
therefore to ensure that not only all children start school but also remain there long
enough to acquire literacy, numeracy and basic attitudes and skills which will help them
improve the quality of their life. There are several factors influencing the educational
achievement of a child and health could be one of them. The extent to which physical ill
health affects the educational status of a child has not been adequately addressed.

Apart from the health and educational problems school age children also have to face
social problems. The social context of a school child here refers to the home milieu.
The social life of children first begins at home. The diet that they receive, the care and
attention they get when they fall sick, the importance given to their education and their
daily activities, reflect their status in the first society they come into contact with, namely
their own home environment. Gender discrimination prevalent in some parts of the
world and also in some parts of lndia adds to the problems of school age children. The
gender discrimination could result in low priority given to a girl in all spheres of life such
as health, nutrition, education and overall importance both in the house and outside it.
She is likely to be considered an economic and social burden, very often neglected
and exploited. In order to bring world wide focus on the plight of the girl child, the year
1990 was declared as the Year Of The Girl Child" by the South Asian Association for
Regional Cooperation -SAARC (Taneja,l990). In this connection, a National
conference on the girl child was also held in lndia with the aim of highlighting the
problems faced by the gill child who was ident~fied as be~ng below the age of 20 years
(Mukhe jee,l991).
It is thus seen that school aye children and especially the girl child constitute a
formidable and challenging group deserving attention by both health care providers
and educationists. To ensure optimum health, education and social status for school
age children, their needs have to be fully understood. The studies that have been done
in the past on some of the health, education and social needs of the school age
children, and particularly the girl child in India, have addressed only specific issues on
an epidemiological approach and have not been comprehensive (Ghosh,1986;

Sathyanarayan et a1.,1990; Booth and Vena,1992; Kapoor and Aneja,1992. Sankar et
a1.,1994; Stivastava and Nayak, 1995; Khadi et a1..1996).
For a better comprehension of their health, education and social status,
qualitative ethnographic research which brings out the community's point of
view, in combination with quantitative sociological and epidemiological studies
which bring out the quantum of the problem wwld be more appropriate. Such
studies need to be canied out particularly in rural areas since, India still continues
to be a land of villages despite increasing urbanization. With these key points in
mind, this comprehensive study combining both qualitative ethnographic methods
and quantitative sociological and epidemiological methods was planned to assess
the health, education and social status of school age children with emphasis on
the girl child, in a rural area.

Jims Jnd Objectives

AIMS AND OBJECTIVES
2.1 Overall aim
The overall aim of this case study is to h~ghlight some of the health,
educational and social issues in school age children with emphasis on the
girl child in a rural area of Tamil Nadu, India. The results of the study will be
useful in formulating appropriate measures to improve the quality of life of
these children.
2.2 Specific objectives
2.2.1 Health
(a) To assess the nutritional status of school age children.
(b) To study the morb~dity pattern of school age children.
2.2.2 Education
To study the educational status of school age children in terms of:-
(a) Magnitude of school
enrollment, school absenteeism and school
dropout.
(b) Causes of school absenteeism and school dropout.
2.2.3 Socioeconomic
(a) To study community perceptions and attitude towards the girl child.
(b) To study the health seeking behavior of the family with respect to their
children.

(c) To study the diet pattern of children wlth reference to difference
between girls and boys.
(d) To study the degree of participation of children in different household
and occupational activities.
(e) To study the influence of menarche on the social status of the girl child.
(f) To estimate the direct cost of illness of the children to the family.
(Q) To find the direct cost of education of the children to the family.
(h) To flnd the cost of celebrating social functions such as attainment of puberty,
rnarrlage and first child birth to a girl in the family.

Overview Of Study Qesign

OVERVIEW OF STUDY DESIGN
This chapter gives a brief summary of the study design includ~ng the reasons for
selecting the place of study. Detailed description of the methodology adopted for the
study of the health, education and social aspects of school age chlldren are glven in
the respective chapters.
3.1 Choice of study area
The reasons for undertaktng the study In a rural area have already been mentioned
(Chapterl: Introduction). In order to address these issues for a state in a satisfactory
manner, data need to be collected from a representative populatton of the state This
will require a large study to be carried out in several randomly selected villages from
different strata (geograph~c, districts, taluks stc.). Before undertaking such a large scale
study, it is important to carry out an in-depth case study , based on the experience of
whlch relevant data can be gathered from a wider area. Therefore, ~t was dec~ded to
carry out an in-depth case study In a single village which would provide reltable
information on the issues. Initially a list of villages with deta~ls about the population slze,
the presence of a primary health center (PHC) and sub center, school, and access~b~lity
was obtained from the local d~strict health officer (DHO). Based on this information, four
villages were visited to assess the feasibility of study. Informal discussions were held
with women who were members of the local "Madhar Sangams" (ladies club). The local
schools were visited and the objectives of the study were explained to the staff
members. After the ln~tial vislts to ascertain the feasibility of the study in the village,
Kedar was chosen for the following reasons -

(a) The village population was reported to be around 3,000 which was consldered
adequate.
(b) There was a government school with pnmary, middle and high school sections and
hence school age children would be available for the study in the village.
(c) The village had a primary health center and a sub-center which could be useful In
canying out the study
(d) Availability of the village health nurse who had been working there for over 7 years,
and who had a good rapport with the villagers.
(e) The villagers were cooperative. Many of them were weavers and would be available
for study during field visits
(f) Studies on school age children had not been done earlier In the vlllage.
(g) The village was accessible by road in all seasons.
After dlscusslons wlth the local medical offlcer and golng through the records
malntalned at the pnmary health center (PHC) and by the v~llage health nurse (VHN) ~t
was found that the date were Inadequate to reflect the extent of occurrences of acute
and chronlc illnesses In chlldren In the vlllage Hence ~t was declded to collect
addltlonal data from a tertlary care hospltal (Jawaharalal lnstltute of Postgraduate
Med~cal Education And Research JIPMER) at Pondlcherry and the Government Chest
Cllnlc Pondlcherry Althougli JIPMER hospltal and the Government Chest Cllnlc are
located In an urban area, the patlents are ma~nly from the surrounding rural areas For
overall morbldlty all chlldren attending the tertiary care hospltal were consldered
However, for health seeklng behavlour only data on chlldren from a rural background
were taken rnto account

3.2 Definltlon of age group for the study
(a) The cross sectional morb~d~ty survey was llmlted to school ch~ldren between the
ages of 5 and 15 years slnce thls formed the school golng age group
(b) For assessing the health educat~onal and soclal status of the glrl ch~ld a cohort
was selected ~n the age group 5-20 years as per defin~t~on of the girl ch~ld by the
Nat~onal Workshop on the girl chlld (Mukherjee,l991)
(c) In order to f~nd out ~f there IS a gender dlscnmlnat~on ~n the att~tude of the parents
In glvlng health care to the~r ch~ldren, data was also collected from JIPMER hosp~tal
and Government Chest Cl~n~c Pond~cherry on ch~ldren up to 15 years of age
3.3 Methods of data collection
Both qualitatwe (ethnographic) and quantitative epidemiological methods were used for
data collection. All the methods used were pretested outside the study village.
3.3 .I Methods of ethnogf8phic study
(a) Key informant intervrew.
(b) Focus group discussions.
(c) In-depth intew~ews.
(d) Nonparticipant observation
(e) Case studies
(f) Structured questionnaire
The above six methods were the tools used to learn about the community's perception
and attitude towards some of the health, education and soc~al aspects of school age
children, especially that of the girl child. Out of these, the first three were the most
important tools used.

3.3.2 Other epidemiological methods
The following epidemiological methods were also used:-
la) Data collected from rural area (study villapel
(i) Census was carried out to define the important demographic characteristics of the
study population.
(ii) Cross sectional school morbidity survey, which included a detailed clinical history
and examination of ch~ldren studying in the village school was conducted
(iii) Random survey of school children was done for causes of school absenteeism.
(iv) A cohort of 215 children between 5-20 years of age were randomly selected from
100 families and followed up fortnightly for, morbidity, school absenteeism,
,nutritional intake and activity pattern for one year. School absenteeism was studied
only in children between 5-15 years of age as they fonned the school going age.
(v) Data were collected from the records maintained by the village health nurse
(VHN) and the primary health center (PHC), on morbidity pattern ~n children.
jb) Data collected from the tertiary care hospital
Data were collected from the following sources:-
(I) The medical records department
3 Data on the nature of illness for which children between 5-15 years of age
attended the hospital were collected at weekly intervals for a period of one year
3 Details of the regularity and duration of follow up ln selected children suffering
from cerebral palsy who attended the hospital over a period of one year were also
obtained.

(11) Pedlatrlcs Inpatlent ward
=> Over a period of 3 months, detalled lnfonnation on health care was obtained from
parents of children who were admitted with acute symptom(s).
LC) Data collected from the Government Chest Clinic
(i) Data on treatment given to children suffenng from tuberculosis over a period of
one year were collected from the clinic records.
3.4 Organization of data and analyses
(a) The qualitative data were organized in Word Perfect version 5.1 and analyzed
using the Text base Alpha software package.
(b) All the quantitative data collected were organized in a computer data base (dbase
IV) and analyzed using Quattro Pro version 5 and Epi Info 6 packages.
(c) The statistical tests applied were Chi-square test, Fisher's exact test. Student's "t"
test , ANOVA. KnrskaCWallis test and Z test for large sample means. Epi info 6.
Quattro Pro, and Epistat software packages were used for the statistical analyses.

TlMB FRAMB OF STUDY (in months)
A Rwiew or lileralure and preparation (3 months)
B Data mUection (22 months)
C Data organization (16 months)
D Data analysis (12 months)
E Preparation and submission of final repon (12 months)

-
Study Qrea Qnd Demography

STUDY AREA AND DEMOGRAPHY
4.1 Introduction
The main study area was a village called Kedar, in Tamil Nadu, South India. The
reasons for choosing the village to prry out the study have already been mentioned
(Chapter 3). This chapter describes the study village, its people and dernographlc
details collected during the initial census. The census also provided scope for
establishing rapport, selection of key informants, members for focus group discussions
and in-depth interviews, and also for nonparticipant observation.
4.2 Description of the village (Kedar)
4 2 1 Land and climate
Kedar is a small vlllage In V~llupurarn dlstrlct Tam11 Nadu South lndla it 1s sltuated
20krn from V~llupurarn whlch IS a dlstrlct headquarters It is In Interior Tam11 Nadu and 1s
about 200 km to tne south west of coastal Chennal the state capltal The vlllage IS
sltuated on a flat dry terraln surrounded by rocky hills The total area is about 687
hectares Most of the area cornpnses dry agricultural lands which are malnly
dependent on monsoon for lrrlgatlon There are a few wells wlth purnpsets The rnaln
crops cultivated are groundnut and paddy apart from other crops llke sesame and
cotton Belng located In the dry southern plalns of Tarn11 Nadu the cllmate IS troplwl
with hot summers and warm winters The temperature 1s fairly high throughout the
year often exceeding 35'C durlng the summer The annual ratnfall 1s around 700 -
1000 rnm

4.22 Itrfreslructun,
The village is located near the main road between Villupuram and Th~ruvannamn.s~ and
is well connected to the neighboring villages and towns by road. It is about one and a
half hours drive from Pondicherry. While most of the houses are thatched huts, there
are a few semipucca and pucca houses. The village has adequate supply of water and
electricity. The sources of water supply are two tanks, two lakes and two bore wells.
Water is supplied to the houses from the two bore wells by pipelines from a water tank
Only few houses have a direct pipeline for water supply, Households which do not have
a pipe supply collect water from public tap or tanks, and store in containen. There is no
drainage system and most of the waste water is let out in the open. Toilet facilities are
available only in 4 or 5 houses, which have their own septic tanks. Medical care is
provided by the primary health center and the subcenter apart from two allopathic
private practitioners, and two faith healers. The village has a government school whlch
has primary, middle and high school sections. At the time of census there were 1,881
students studying in the school, out of which 1.031 were from Kedar and the rest from
the neighboring villages. The total number of teachers m the school was 33. The
student teacher ratio in the pnmary section was 52.4 and middle school was 56.4. The
village has a police stabon, a telephone exchange, a panchayat office, a -operative
society and a hostel for school boys belonging to the scheduled caste. There are also
four Hindu temples. Festivals are celebrated throughout the year.
4.2.3 People
The people of Kedar are generally simple, quiet by nature and are socioeconomicsllY
backward. Most of them are Hindus. The people are predominantly agricultural
laborers, weavers and cultivators. The others are artisans, petty shop owners or

government servants. The language spoken 1s Tamil. The village also has a population
of scheduled caste who live in an adjacent hamlet.
4.3 Demography and socioeconomic features
4.3.1 Method of data collecffon
Data were collected by carrying out a census at the beginning of the study. A door to
door visit was made and relevant details about the people entered on a predesigned
and pretested proforma. The demographic features of the village was compared wlth
those of the state and the natlon. Census, which was taken over a period of 3 months,
provided scope for cross sectional data collection at one point of time on some issues.
It gave an opportunity to establish rapport with the people, ident~fy key Informants and
prospect~ve members for focus group discussions and in-depth interviews and to make
nonparticipant ObSe~atlonS Although information or1 ~mmun~zation details was
collected during census, only those results pertaining to the demographic, some
educational and socioeconomic aspects are presented here
Data on some important health indicators were wllected from the PHC
4.3.2 Results
ja) Demoaraphy
There were 658 households In the village wlth a total population of 3,068. The sex rat10
(number of females for every thousand males) was 1,004 against a sex ratio of 927 for
India and 1,032 in Tamil Nadu (Anonymous,l994a; Park.1997). A comparison of the
age and gender specific distribution of the village population with that of Tamil Nadu

and India, is given in Table 4.1. Of the total population in the village. 31.7% were below
15 years of age and 10.0% 60 years and over. the wrrespondlng figures for Tamil
Nadu being 31.4% and 8.7% respectively (Anonymous,l995). The overall age and
gender distribution of the population in the village was simllar to Tamil Nadu and Ind~a,
except that the sex ratlo was higher than the national figure and less than the state
f~gure. In Figure. 4.1 the age and gender specific distribution of the population of Kedar
is shown Except for one muslim family in the entire village, all were Hlndus. Out of 658
households, 185 (28 1%) belonged to the scheduled caste, who formed 25 7% of the
total population.
jb) Occupation
Out of the total village population, 35 0% were landless agricultural laborers, 25.0%
cultivators.l8.0% businessmen,l7.0% weavers and the rest petty shop owners,
government servants etc. (Figure. 4.2).
lc) Literacy status
The overall literacy rate of the v~llage population over 6 years of age was 63.0%. It was
significantly higher in males (74.6%) than in females (51.7%; p c 0.05). The male and
female literacy rates in the village were higher than those in Tamil Nadu rural areas and
in Ind~a. The literacy rates for women and men in rural Tamil Nadu are 47.0% and
71.0% respectively, and the corresponding figures for India are 37.7% and 65.5%
respectively (Anonymous,l994a; Park,l997).
id) Socioeconomic status
Most Of the villagers belonged to a low socioeconomic status. Out of a total of 658
households, 466 (70.8%) had an annual income of less than Rs.10,000 (Table 4.2) and

74.8% were landless (Table 4.3). Among the land owners, only 4.2% owned more than
5 acres of land. The distribution of the village population according to the type of
houses they live in is given in Table 4.4. A majority of the villagers llved in huts.
je) Health indicators
For the year 1996, the crude birth rate, crude death rate, infant mortality rate and ch~ld
death rate in the village were reported to be 18.6/1,000, 8.7/1,000, 43.4/1,000 and
2.7/1,000 respectively from the local PHC sources. There were no maternal deaths and
no report of infanticide from Kedar.

TABLE 4.1
AGE AND GENDER SPECIFlC DISTRIBUTION OF VILLAGE POPULATION
AGE FEMALE MALE TOTAL SEX TAMIL INDIA
(YEW) RATIO Y N4DU ' RURAL '
04 136 171 307 795
TOTAL 1537 153 1 3068 1004
Source : Anou)mous 1995
** Number in parenthesis corresponds to % of total (n)
# Sex ratio : number offemales per 1,000 males

TABLE 4.2
DlSTRlBUTION OF HOUSEHOLDS
ACCORDING TO ANNUAL INCOME
INCOME NUMBER PERCENTAGE
(RUPEES)
OF TOTAL
>20,000 41 6.3
TOTAL 658 100.0
TABLE 4.3
VISTIUBUTION OF HOUSEHOLDS
ACCORDING TO LAND HOLDING
LAND NUMBER PERCENTAGE
(ACRES)

TABLE 4.4
DISTRIBUTION OF HOUSEHOLDS
ACCORDING TO TYPE OFEOUSES
HOUSE TYPE NUMBER PERCENTAGE
THATCHED 483 73.4
TLLED 90 13.7
PUCCA 85 12.9
TOTAL 658 IUU.0

I
FIGURE 4.1
Age and gender distribution of village population
I
I
AGE GROUP IN YEARS&
I
&: The claaa intervals have been chosen differently to show the details of
class of Interest and also to compare with the corresponding age groups i
state and the nation

Distributlon of adult village population
according to occupation

HeaCth Status Of SchooGjiige Chiliiren

HEALTH STATUS OF SCHOOL AGE CHILDREN
5.1, Introduction
There are about 1,000 million school age children in the world (Bundy and
Guyatt,1996). They form a very important group because they are in the fonat~ve
stage and are the future builders of the nation. In addition, through them, their families
and communities could be reached. The physical and mental well being of school age
children can influence the health status of a larger segment of the population. Of all the
factors that contribute to the optimum growth and overall development of a child, good
health can be considered to be a very important factor. However, very little is known
about the disease burden in this age group (Bundy and Guyatt,1996). Data of good
qual~ty is essential to assess their specific needs which may vary from country to
country. Physical ill health in school age children is likely to influence their educational
achievement. Some of their illness burden can be reduced either by intervention or
inculcating appropriate behavior pattern by health education. The following IS a review
of their current health status and their health needs.
5.2. Review of literature
5.2.1. General morbidity in school age children
la) Global scenario
In 1990 there were estimated to be 1,080 million school age children (5-14 years Of
age). They shared a total burden of 150 million DALY which was 11.0% of the global
burden of disease for all age groups (Bundy and Guyatt,1996). Th~s may be an

underestimi~te because it excluded DALY lost to conditions that had their onset In
infancy and conditions tliat may arise subsequently due to health related behavior
during scholl age. The DALY lost were 53.0% from communicable diseases, 28.0%
from non communicable diseases and 18.0% from injuries (Bundy and Guyatt,1996).
Neuropsychiatric disorders were also important causes of DALY loss in school age
children. Some of the other causes are accidents, respiratory disorders, acquired
immunodeficiency syndrome (AIDS) and other sexually transmitted diseases (STD).
Though malnutrition and infections still remain as important causes of morbidity In
developing countries, problems such as substance abuse and suicide are also seen In
them. The latter two arise with urban migration, increased unemployment and
disruption of traditional soclal structure which are lncreaslng In develop~ng countries
(Blum,1991~.
The predominant health problems in school age children in developed countries are
different from those in the developing countries. Some of the problems :re related to
rapid growth and development. The period between 10-15 years of age forms the early
or young adolescent period and is generally clubbed with the adolescent perlod.
Young adolescents fall ill more often than older adolescents. The common illnesses as
seen in a hospital survey in the United States Of America are respiratory illness
(21.0%) followed by injuries and poisoning (16.0%; Litt,1996). A school survey In the
Unlted Kingdom also revealed that children suffered from headaches, dental problems,
respiratory infections, skin, eye and welght problems. More than these physical
allments they suffer from a variety of psycho-social disorders, drug abuse, truancy and
sleep problems (Macfarlane et al,1987; Oppong and Meycock,1997, Blader el a1.,1997,
Berg,19Q7). Another study, also from the Unlted Kingdom, showed that the prevalence

of chronic illnesses in children less than 16 years was 11 1 per thousand. Most of the
illness were due to disorden of the respiratory system (20.0%), nervous system
(14 0%) and musculoskeletal system (11.0%; Pless and Douglas,1971)
Out of the total DALY lost in school age, 97.0% is In the developing countries. lnd~a
and Sub-Saharan Africa share almost half the burden. lnfect~ons and parasltlc d~seases
are the leacling causes of DALY loss in developing countries. In Sub-Saharan Africa,
the DALY lost is 10 times higher than that in developed countries. Out of the total
DALY lost In school age children, 70.0% is attributable to communicable d~seases.
Other important conditions that contribute to DALY loss in developing countries are
lnfectlons and parasitic diseases including intestlnal helminths, tuberculos~s, malana,
vacclne preventable illness, Schistosomiasis, Chagas disease, acute lower respiratory
infection, chronic respiratory dlsease and d~arrheal dlseases (Bundy and Guyatt,1996)
Ib) Indian st-
(I) Growth
Growl I 1s a sens~tlve lndlcator of health Durlng school age there 1s an average welght
galn of 3 Okg-3 5 kglyear and he~ght galn of 5 Ocms-6 0 cmslyear There are two
growth spurts seen In thls stage, one around 6-8 years known as the preadolescent or
m~d growth spurt and the other IS the adolescent growth spurt that takes place between
12-17 years of age Though the growth standards developed by the Nat~onal Center
for Health Stat~stlcs USA (NCHS) are extensively used world over the data published
by Pqalwal and Agarwal (1992) prov~des a good reference for lnd~an studles
(Mukherjee 1997) It has been found that the growth of affluent lnd~an ch~ldren was
comparable to the~r western counterparts In the preadolescent and early adolescent

period, but the ultimate height and weight were less than that of their western
counterparto (Sundaram et a/. ,1088; Vir, 1090; Agarwal et a/. ,1092).
It is well known that adolescent growth spurt occurs earlier in girls than in boys. Up to
the age of 10-10.5 years of age a mean height increase of 5.0cms-6.0 cmslyear was
observed for both girls and boys. After that an accelerated growth in height was seen
in girls up to 13 years of age and in boys afier 13 years (Rao et a1.,1984; Qarnra et sl.,
1990a; Agarwal et aL,1992). Thus girls were taller than boys between 11-13 years of
age. They were also found to be heavier than boys between the ages of 9.5-14 years.
The mean height gain observed in girls and boys between 6 and 14 years of age from
a rural area was 32.lcm and 34.6~1 respectively and the corresponding mean weight
gain was 14.9kg and 13.7kg respectively (Rao et a1.,1984). Affluent girls between 10-
15 years of age were found to gain 17.5 cm in mean height and 15.1 kg in mean weight
(Pereira et a/., 1983). A study carried out by Agarwal in 1992. also in affluent girls,
showed that in the age between 9.517 years, girls gained 22.1 kg and boys 29.8 kg in
weight. In another study by Qamra in 1990, it was observed that the body mass index
(BMI) ol g~rls remained constant between 59 years of age (0.13 in upper
socioeconomic status:USES; and 0.14
in lower socioeconomic status:LSES).
Thereafter it increased to 0.15 in USES and 0.16 in LSES girls up to 13 years of age.
Beyond 13 years the BMI showed a rapid increase up to 16 years (the age up to which
the study was done) (Qamra et a1.,1990b).
A wide variation is seen in the growth pattern of school age children in India. Studies
have shown that the growth of girls and boys from USES is higher than those from the
LSES (Pereira el a1,1983; Rao el a1.,1984; Sundaram et a1.,1988; Qamra et a/.,1990c8

Bhasin et a1..1990; Gupta et a1..1990; Joshi et a/., 1994; Singh et a1.,1996). Qamra
(1990~) observed that girls who consumed inadequate calories were significantly
smaller than girls who consumed adequate calories. Moreover, ~n h~study he found
that while 91.2% of girls from the LSES consumed inadequate calories, only 38.2% of
girls from the USES did so. This probably explained the better growth of girls from the
USES. Spatial variation in growth pattern is also observed in d~fferent parts of the
country. Girls from South India were shorter by 2.0%4.5% than their counterparts from
North India, especially between 9-13 years. However, they became comparable by the
age of 17 years of age (Chattejee and Mandal.1991). Likewise, it was observed that
boys between 9-18 years of age from West Bengal were taller and heavier than the
South Indian boys (Chattejee and Manda1.1994). This variation could be as a result of
d~fferent environmental conditions, nutritional status and socioeconomic conditions.
The educational level of parents also might have a significant impact on growth and
nutrit~on (Chattejee and Manda1,1994).
(ii) Menarche
Menarche IS an important biological event in a girl's life. It is not only a landmark in a
girl's developmental process, but the age at menarche is also an indirect indicator of
her health and nutritional status. The averageage at menarche is generally between
12-14 years. However, in some studies the mean age at menarche was 11.5 years and
In some, it was observed to be well over 14 years (Logamabal and Rao,1979;
Singh,1986). The timing of menarche is detenn~ned by the girl attaining a certain body
weight ard also height (Vir,1990; Ludwig,1994; Kuteyi et a/.,1997). A strong and
Positive association was found between the nutritional status and attainment of
menarche (Kuteyi et aL,1997). The mean age at menarche was lower In affluent girls,

eing 12.6 years when compared w~th girls from rural areas where it was 13.9 years
(Joseph et a1.,1997). Thus the age at menarche could be an indirect indicator of a girl's
nutrilional status.
(iii) General disorders
Compared to the under five's, the school age children are generally healthier. Both
hospital and community based studies have been carried out to study the morbidity
pattern in them
The data available on the health status of school age children are
heterogeneous. Different studies include different age groups, focus either on a single
illness or on general morbidity conditions. A community survey near Calcutta showed
that the average illness in children between 6-14 years of age was 3.21girl and 3.7lboy.
It was hlghest in chlldren between 1-3 years of age and lowest in children between 6-14
years (Choudhun and Choudhuri,l962). The average disorderlchild in other studies
var~ed from 1.3 to 3.2 (Gupta et a1.,1973; Ananthakrishnan et a1.,1987). Surveys have
shown that the percentage of children suffering from some disorder or the other to vary
from
46.5% In Lucknow to 83.0% in Bombay (Bansal et a/.,1973, Tragler,l981:
Khanna et a1,1995).The morbidity rate was higher in children below 10 years of age
(87.1%) than in older children (67.7%; Bansal et a1.,1973). Some of the common
causes of morbidity as revealed by different studies were nutritional disorders, diseases
of the skin, hair, eye, ear, nose and throat, respiratory system, dental wries,
helminth~asis, tuberculos~s, convulsions and anemla (Gupta et a1.,1973, Bansal et
a1,1973, Aganval et a1.,1976; Tragler,l981; Ananthakrishnan et a1.,1987; Bhattacharya
and Tandon,1992, Khanna el a1.,1995;Table 5.1). The prevalence of these disorders
as revealed by different studies showed a wide variation. The reasons for thls vanatlon
have not been looked into. The morbidity in school children from Pondicherry as

eported by ttie School Heallh Cell, over a period of 7 years is shown in Tablo 5.2.
WIIIIII
11~~n~lmIl~~1~. n~laloin n11(I r(0111ml (.~IIPU were 1110 rnllllllnll rl~n~li~rl~ly rnrirltl~n~is
observed. This data also showed some variation in the prevalence of different disorders
over the years. Th~s var~atlon could either be due to a d~lference in the occurrence of
these disorders or due to differences in the methodology employed in d~fferent years.
5.2.2. Specific morbidity in school age children
la) Intestinal parasitic infections
(I) Global scenario
An important cause of morbid~ty in school age children is worm infestation. According to
the world development report 1993 (World Bank,1993) intestinal worm infestation is the
leading cause of morb~dity in children of school going age accounting for 10.6 and 9.2
rnill~on of DALY loss in males and females respectively. It was estimated that 10.0% of
young chlldren living in conditions appropriate for hyperendemic geohelminth
transmission could have an infestation sufficiently intense to cause chronic colitis and
growth retardation (Cooper and Bundy,1986 and 1988). The prevalence of Tnchuns
and Ascaris was reported to be very high in West Indies. It was 75.0% to 85.0% for
Trichuds and 80.0% to 70.096 for Ascens in dlfferent areas (Didier et a/..le88). In a
study from Jamaica, moderate to heavy loads of Trichuris infestation was found to have
a detrimental but reversible effect on certain cognitive functions in ch~ldren (Nokes et
a1.1992; Lemma and Bundy,1987). A high prevalence of Tnchuris (62.8%) and Ascan's
(49.6%) has also been reported from Malaysia (Bundy ef a1.,1988). A recent study from
Nepal showed that the prevalence of intestinal parasites was as high as 74.4% Ascaris
was the commonest (21.8%) followed by Giardia (18.5%) and Entamoeba h~stolytica

(12.8%). Hook worm was found in 6 2% and Trichuns in 5.2% of the children surveyed
(Reddy et aL,1998).
(ii) Indian scenario
In India, studies have shown that the prevalence is generally higher in children when
compared to adults as in most developing countries (Khan et e1.,1988,
Anonymous,l987; Baveja and Kaur,1987; Sharma and Mahadik.1988). Paras~tic
infections are also more common in rural areas (Nagoba et a1.,1992). The overall
prevalence in different parts of India varies from 16.8% to 62.3% (Baveja and
Kaur,l987; Sharma and Mahadik.1988). Some studies have revealed a higher
prevalence of protozoan parasites than intestinal helminths (Baveja and Kaur,1987,
Sharma and Mahadik.1988). According to Sharma and Mahad~k (1988), In rural
Rajasthan, the prevalence of Entamoeba histolytica was 17.5% and Giardia 27.2%,
while that of both Ascans and Enterobius was 0.9% each. Baveja and Kaur (1987)
have also reported a h~gher prevalence of Entamoeba histolytica (10 0%) and Giardia
(7.5%) than Ascaris (1.4%) and Ankylostoma (1.2%) in Delhi. In ~ ral West Bengal,
Saha et a/. (1993) found a prevalence of 34.8% of Ascaris. 8.3% of hookworm, 29.2%
of Giadia and only 6.9% of Entamoeba histolytica. A study from Kamataka also
revealed a high prevalence of 46.9% for hookworm, 43.8% for Trichuns and 8 4% for
Ascaris (Subbannaya et a1.,1989) The prevalence of Ascaris, hookworm and Trichuns
~n rural Pondcherry was 10.1%, 4.8% and 5.4% respectrvely. In urban Pondicherry the
correspondtng prevalence rates were 1.8%, 0.2% and 2.8% respectively (Reddy and
Venkateavaralu, 1992).

lb) Anemia
(i) Global scenario
Nutritional anemia is a global problem. It has been estimated that 1.3 billion individuals
all over the world were affected by anemia. The prevalence in developed countries IS
about 8 OOh, whereas in developing countries it is as high as 30.090 (United
Nattons,1992).
Young children and women in reproductive age group are most
affected by anemia. It shows a higher prevalence among people of LSES than people
of USES.
Iron deficiency anemia decreases resistance to infection and tmpalrs
physical work capacity (Viteri and Torun,1974; Srikantia et a1.,1976; Edgerton et a/,
1979, Basta et a1.,1979, Sathyanarayana et a1.1990). It has been estimated that nearly
200 mllllon preschool and school age ch~ldren have learning dlsablllty and perform
suboptimally as a result of anemia (United Nat1ons.1992).
(11) lndtan scenarlo
Large populat~on surveys carr~ed out In lnd~a ~ndlcate that anemla IS prevalent ~n all age
groups of the lnd~an populat~on It 1s h~gher ~n the rural areas as compared to urban
areas (Bhaskaram 1995) In some areas the prevalence was as h~gh as 65 0%-75 0%
(Kanant 1995) It IS prevalent In gtrls of both USES and LSES as shown by Kapoor
and Aneja (1992) He observed that anemla was present In 46 6% and 56 0% glrls from
the USES and LSES respect~vely Anemta was also a slgnlf~cant problem tn school
boys ~n whom the prevalence was between 45 0%-55 0% (Anonymous 1982)
Hookwotrn 1s known to be an lrnportant cause of anemla The prevalence of anemla IS
expected to be hlgh In places where hookworm lnfestatlon IS also wtdely prevalent as

observed in Calcutta (Anonymous,l982). Many young people are aware that low iron
content and poor availability of iron is a major cause of anemia (Kapll et a1.,1991). The
low iron content of the average Indian diet of rice and dhal has been observed by some
Investigators (Aspatwar and Bapat,l9Q5). A combination of school and community
based health education and supplementation was found to cause a significant
decrease in anemia (Kanani,1995). The national program for prophylaxis against
nutritional anemia targets pregnant and lactating mother and children upto 12 years of
age only (Park, 1997).
[c) Vitamin A deficienct
(i) Global scenario
It has been estimated that about 40 mill~on children in the world suffer from vitamin A
deflclency of whom 4,00,000 have some degree of eye damage Every year 2,50,000
preschool children d~e of complications associated with vitamin A deficiency. More than
30 0% of these children belong to South East Asian countr~es (United Nations,l992).
(ii) lndlan scenarlo
It has been estimated that 52,000 children become totally blind and 1,10,000 - 1.32.000
become partially blind every year due to vitamin A deficiency
in India
(Bhaskaram,l995). There is a w~de variation in the prevalence of vitamin A deficiency
in different parts of lndia ranging from 0.3% to 86.0% (Garg et a1.,1986, Aspatwar and
Bapat,1996: Table 5.3). The variation in the prevalence could be due to seasonal
variation ,r
due to different methods employed in detecting this disorder (Garg et
a1.,1983). Various methods have been used to diagnose vitamin A deficiency. These
include the following:- i) assessment of dietary vitamln A; ii) biochemical assessment of

serum vitamin A; iii) ophthalmological evaluation for clinical signs of vitamin A
deficiency; iv) Rose Bengal Stain test for early conjunctival xemsis and v) conjunct~val
impression cytology for preclinical vitamin A deficiency. S~nce the techniques employed
were not uniform, the results are not strictly comparable. In some studies, the
prevalence of vitamin A deficiency was significantly high in school age children making
it an important health problem (Desai et a1.,1989; Sampathkumar and Abe1,1993.
Sharma et a1.,1993). Studies have shown that the dietary intake of vitamin A by
children was less than the recommended dietary allowance (Aspatwar and Bapat,l995
and 1996).The existing scheme for control of blindness due to vitamin A def~ciency
covers children up to 6 years of age only and does not include school age ch~ldren who
might be suffering from vitamin A def~ciency (Park, 1997).
Id) Riboflavin deficiency
Recent surveys conducted by the National Nutritional Monitoring Bureau suggest that
riboflavin is one of the most limiting nutnents in Indian diets (Prasad et a1.,1987). In a
study from Hyderabad, it was observed that 82.0% had biochemical riboflavin
defic~ency and only 15 5% of those with deficiency presented with clinical signs of lt
(Prasad et a1.,1987). In a rural area near Hyderabad, it was found that the prevalence
of riboflav~n defic~ency was 41.3% (Bamji et a/., 1979). The prevalence varies from
8 0% to 27.0% in different parts of the country (Rao ef a1.,1984; Gupta,1989).
[el Periodontal disease
The prevalence and severity of periodontal diseases vary according to geographical,
social, local, oral and systemic factors and oral habits. A prevalence rate of over 40.0%
has been recorded in many countries (WH0,1978).
In different parts of Ind~a, the

prevalence of periodontal dlseases In school children vaned from 28.0% to 41 7%
(Pandit et a1..1986; Goyal et a1.,1994).
Comparison of prevalence and severity
between wuntries is difficult because of different diagnostic uiteria and methods of
assessing periodontal disease (WH0,1978).
fl Dental caries
WHO has set a global indicator for oral health status as an average of not more than
three decayed, missing (on account of caries) filled permanent teeth (DMFT) at the age
of 12 years (Goyal et a1.,1994). Dental caries is widely prevalent all over the globe and
the prevalence in school children in lndia showed a variat~on in different parts between
16.5% and 54.0% as shown in Table 5.4 (Rao and Bharambe, 1993; Gathwala, 1993).
The d~fference In the prevalence rates could be attributed to differences in the d~etary
pattern and oral cleaning habits.
Lq) Iodine deficienc~
Iodine deficiency is a public health problem in 95 countries worldw~de
(Bhaskaram,l995). The prevalence of goiter in school age children in different parts of
lndia ranged from 3.0% to 70.0% as shown in Table 5.5. A high prevalence of goiter
and cretinism was found in a broad Himalayan ana sub-Himalayan goiter belt from
Jammu and Kashmir in the North to Arunachal Pradesh in the East. A high incidence of
goiter has also been rewrded in Maharashtra, Gujarat, Kerala, Mizoram and Sikkim.
(Bhaskaram.1995). In India, no state is free from iodine deficiency. Though goiter is not
mdely prevalent in Tamil Nadu, it has been found endemic in some districts (Pandav
and Anand,l995). The overall prevalence of goiter in lndia is 21.0%. As a measure to
Wntrol goiter, lndia has adopted the strategy of "Universal iodization of Salt by 1995

and elimination of iodine deficiency disorders (IDD) by the year 2,000 AD"(Pandav and
Anand,l995). Tamil Nadu is one of the states where sale of noniodized salt 1s banned
by the government.
jh) Chronlc suppurative otitis media (CSOM]
Chronic suppuratlve otitis media (CSOM) is an important cause of morbidity in school
age children. It is seen in developed countries also. Surveys in the USA and England
have shown a prevalence of 3.0%-5.0% of chronic otitis media in children
(Johonnott,l973). It was observed that in Alaska, the prevalence was much higher in
those children with poorer sanitation and socioeconomic status than in those with better
sanitation and socioeconomic status (18.3% vs. 4.4% respectively: Johonnott.1973). In
India, the prevalence of CSOM varied from 9.0%-15.0% (Khanna et a1..1995). It is an
important cause of deafness in children. Studies have shown that more than 50.0% of
children with CSOM have got impaired hearing (Table5.6)
[il Deafness
School children in India are generally not screened for hearing loss during routine
health checkup. Few studies carried out have shown a prevalence ranging froill
11 9%-17.2% (Kapoor,l965; Tuli et a1,,1988; Verma et al..l995).Conductive loss,
commonly due to CSOM was found to be the most common cause of deafness In a
study from Haryana, it was observed that 71.6% of children with hearing loss had
CSOM (Verma et a1.,1995). Deafness is more common in rural areas than urban areas.
The higher prevalence is attributed to improperly managed upper respiratory infectlons.
low literacy, lack of health consciousness, malnutrition and swimming in dirty ponds
(Tuli et a/., 1988).

U) Headache
The data on childhood headache is sparse and most often related to migra~ne. The
prevalence of headache has been recorded to be 3.5% in ch~ldren (Collin et a1.,1985).
It was observed that by the age of 7 years, 40.0% of children would have experienced
headache and by the age 15,the figure would rise to 75.0%. The frequency increased
w~th age. Gender differences were found in older children aged 10-15 years, glrls
having more headaches than boys (Gascon,1984)
Ik) Rheumatic heart disease (RHD) and conaenltal heart disease (CHD)
The incidence of Rheumatic fever and prevalence of RHD show marked variat~on from
one country to another. The Incidence in industrialized countries IS less than 5/1,00,000
population. In developing countries the incidence is likely to reach 100/1,00,000 in
ch~ldren. The prevalence of RHD in various countries is given in Table 5.7(WH0,1988)
The observed prevalence in a study from Delh~ was 0.14% or 1.411,000 (Vash~stha et
a/., 1993). The screening of children of school age for RHD and the creation of registry
for cases detected are essential components of a program for reducing the incidence of
Rheumatic fever (WH0,1988). In a survey from Delhi, the prevalence of CHD was
found to be 5.2/1,000 which was higher than the prevalence rate of RHD (Vashistha et
a1 ,1993a).
[I) Disorders of the eye
Eye diseases are common in school children. In a study from the United States Of
America, the prevalence of ocular disorders in school children was found to be 22.3%.
Refractive error was the commonest among the various eye disorders, being reported

in 15.7% of the children screened (Choi et a1.,1995). Rodriquez and Gonzalez (1995)
have reported a very high prevalenw (48.0%) of refractive error in Colombia. In some
African countries, measles keratitis and Onchocersiasis related eye lesions were
common (Ajaiyaohs,lQQ4; Umeh et el.,lQQ5). Cataract was a common cause of
blindness in children in Cambodia (Thomson,1997). In India, the prevalence of eye
disorden in school children varied from 2.0% to 20.0% (Rao et aL,1964; Goyal
et a1.,1989). A study from Mee~t
showed the prevalenw of refractive error to be 8.7%,
trachoma 5.0%, visual disturbance 1.3O/0, disorders of conjunctiva 1.3%, inflammation
of eyelids 0.9% and disorders of lachrymal system 0.4°/~ (Garg et a1..1986). In another
study, it was observed that 9.0% had refractive error, 1.7% had conjunctival disorders.
0.6% had inflammat~on of eyelids and 0.5% had trachoma. Ocular morbidity was
maximum between 610 years of age (Goyal et a1.,1989).
jm) Abdominal pain
Abdominal pain is a common symptom in children with a prevalence of 10-15% in
school aged children in different parts of the world. It is more common in girls than
boys The prevalence is higher in the 8-12 year age group (Appley and Naish,1958;
Oster,1972; Rappaport,l989). In developed countries, psychological or nonorganic
causes were found to be important etiological agents of abdominal pain (SEwena,I979).
On the other hand, in India, worm infestation and abdominal tuberculosis were the
common causes of abdominal pain (Kulshresthe et al.,l976). In a study from
Pondicheny, organic etiology was found in about 51.0% of children with abdominal
Pain, the leading cause being intestinal parasitic infection (Thakur,l996).

~n) Others
Bes~des the common morb~d~ty cond~tlons In school age chlldren discussed above
there were also other causes of rnorb~d~ty llke acc~dents Injuries, polsonlng, behavlor
d~sorders substance abuse, alcoholrsm, smok~ng etc wh~ch have been extens~vely
studled (Mohan, 1996, Tandon et el, 1993, Kapoor et a/, 1995)
5.2.3. School Health Services (SHS)
The review on the morbidity of school age children is not complete without the appra~sal
of the health infrastructure available for the care of school age children.
Lal Global scenario
Each country has got a system of its own that looks after the specific needs of the
school age children. In 1995, a WHO Expert Committee on comprehensive school
health education and promotion reviewed the status of school health programs, the
strategies used to strengthen these and research that can be used to improve these.
As a result, the Global School Health Initiative (GSHI) was started. Globally schools
reach about 1,000 million young children and through them their familles and
communities. Therefore, these could be util~zed effectively to improve the health of
pupils, staff, families and members of the community. The goal of GSHI is to Increase
the number of institutions that can truly be called health-promoting schools. A health
promoting school is one that adopts the following principles:-
-> Engagns health and educat~on off~cials, teachers, students, parents and comrnunlty
leaders in effort to make the school a healthy place
3 Implements policies, practices and measures that encourage self esteem

3 Strives to prov~de a healthy environment school health education and school healtin
services along with schooVcommunity health projects
:, Stnves to improve the health of school personnel, famil~es and community members
as well as pupils
Works with community leaders to help them understand how the community
contributes to or undermines health and education
The GSHl has been implemented In several developed and develop~ng countnes with
sat~sfactoty results (O'Byme ef a1.,1996).
jb) Indian scenario
In India, School Health Service (SHS) was first started in Baroda city In the year 1909.
The broad object~ves of school health services are as follows:
3 Promotion of positive health
a Prevention of diseases
1 Early diagnosis, treatment and follow up of defects
=1 Awakening of health consciousness in children
=1 Prov~sion of healthy environment
The various aspects of SHS are:-
.=. Health appraisal of school children and personnel
Remedial measures and follow up
.=. Prevention of communicable disease
3 Nutiitional services
3 Healthy school environment
3 First aid and emergency care

=-. Mental health
=, Dental health
Eye health
3 Health education
-1 Education of handicapped children
=, Proper maintenance and use of school health records
The primary health centers are given the responsibility of administering school health
service within their jurisdiction. On an average, each doctor has to approximately look
after 1,500 ch~ldren In reality, only health appraisal of school children 1s done and a
few remedial measures are given which are limited to distributing vitamin A B D
capsules, B complex tablets, iron and folate tablets, antihelm~nth~cs and scab~cldal
lotton to a few students depending on the stock position of drugs About 300-400
chlldren are examined in a single day and the doctor completes his task in 3 or 4 days.
The average time spent on each child is approximately 1-2 minutes. Other aspects of
SHS are not given time and attention. None of the national health programs are
~mplemented through the SHS. Owing to several reasons, none of the SHS existing in
India today are functioning satisfactorily. One important reason for th~s being that, the
PHC medical off~cer mainly having to shoulder the responsibility of giving health care to
several school children in addition to his many other responsibil~ties. Gupta (1983) has
Suggested that a centrally sponsored school health program (SHP) be launched In
which many components of the SHP including health and nutrition education could be
taken core of by the school teachers, with proper guidance and support from the
education and health authorities. He also felt that the main focus should be on health
and nutrition education aimed not only at providing knowledge but also at inculcating

nght attitudes and practices. In order to involve the paramedical workers and teachers
In giving health care to school children, the Government of India launched a scheme for
health check up of primary level school students in the year 1996. Accordingly, dunng
the period July 22-27. 1996, 100 mlllion children enrolled in primary schools all over the
country were examined by a team of health nurses, teachers and helpers. The
emphasis was once again on health appraisal and remedial measures only, and not on
health and nutrition education.
5.3 Methodology
A detailed protocol was designed, taking into consideration the vanous issues raised
under objectives. Both ethnographic and quantitative methods were employed to collect
data. Ethnographic methods were used to study the people's perceptions on the Issues
and quantitative methods were used to bring out the epidemiological features. More
than one method was employed to obtain data on most of the Issues. The cho~ce of
methods was determined by the issue and logistics. The qualitative data pertain~ng to
health, educat~on and social aspects were collected separately for each one of them.
All the ehlnographic quamtitative data were collected concurrently using a single
questionnaire. The instruments (proforma, forms, questionnaire etc.) and methods used
were pretested In the neighboring villages. The study deslgn described below deals
w~th the choice of the method in relation to the issues (Table 5.8A and 5.86).
description of the method, timu frame of activities and also the statistical methods
applied for analyses .

5.3.1 Descriptbn of methods
la) Ethnographic Methods
Ethnographic methods are used to collect descriptive plctures of what people actually
perceive and do The methods are flex~ble and enable the researcher to revlew events,
action, norms, values etc, from the perspective of people who are be~ng studied.
Thereby the researcher is able to gather a holistic understand~ng of the psycosociocultural
settings in which the research is being conducted (Hudelson,l994).
The ethnographic methods used in the current study Included focus group discuss~ons,
In-depth lntervrews, key informant interview and nonparticipant observation. Focus
group discussions (FGD) are designed to obtain information on part~cipants' beliefs
and perceptions on a given issue. The moderator uses a predetrrmined list of open-
ended questions which are arranged in a logical sequence, lndepth interviews (IDI)
intens~vely Investigate a part~cular issue In a glven indiv~dual. The purpose is to gain as
complete and as detailed an understanding as possible of the concerned issue. The
lnte~iews are usually held with the help of a semistructured interview guide. In a key
informant interview, information on various issues is gathered from carefully chosen
key informant(s) at different points of time uslng informal discussion. Nonparticipant
0bbe~ation~ are chancelplanned observation made on specific issues informally over
a long period of t~me.
(i) Key informant interview
During the process of taking census, rapport was established with the community and 2
key informants were identified. They were, Selvi, a 18-year old girl who had completed

her schooling (XI1 standard) and was waiting for the results and Anandhi a 20-year old
girl who had completed nursing training and was awaiting a job They were chosen
because they were educated, and having grown up in the same village, they
understood the local culture and peoples' perception very well. They were
comrnun~cat~ve, and during initial interactions proved to be frank, open and reliable.
Being educated, they also understood the importance of carrying out a scientific study.
The key informants helped to identify members who could take part in the group
d~scuss~ons and also indlvlduals who could respond to In-depth inte~lews. Most of the
information was obtained from the key informants' during lnformal conversations held In
either of their houses or at opportune moments during field activities
(ii) Focus group discussions and indepth interviews
a Pretesting
Pretesting for focus group discussions was done to assess whether the questions used
in the guide were appropriate and sequential. It also helped to test whether the
d~scussion generated was free flowing and relevant to the issues. Further, it enabled
the investigator to gain experience on moderatton As far as In-depth lnterwews were
concerned, pretesting helped to assess the appropriateness of the questions and gain
experience on the technique Focus group discussions and in-depth interviews on
Issues pertaining to health were initially held in two villages outside the study village
before being conducted in the study village.
= Data collection in the study village
Focus group discussions were held with groups of women, men, children, teachers and
health professionals. Such diverse groups were selected for discussions because, It

was Intended to collect a w~de cross sect~onal vlew of the community on health
problems of school age ch~ldren Only such of those who were w~ll~ng to talk freely
were selected for the dlscuss~on w~th the help of the key informants Each group had
8-10 parhapants These dlscuss~ons were mostly held In the VHN s res~dence They
were generally conducted ~n the forenoon around Ila m or In the afternoon around
3 30p m since the partlc~pants were free to take part In the dlscusslons only dunng
these hours The dlscusslons were moderated by the lnvestlgator herself and each
lasted for about 1-1 5 hours
All the d~scuss~ons were recorded on aud~o tapes afler
taklng Informal consent from the partlclpants A total of SIX focus group dlscuss~ons
were held The groups were as follows -
1 Two groups each comprlslng 8 marr~ed women (25-45 years old) w~th ch~ldren
2 A group of 8 marr~ed men (30-45 years old) w~th ch~ldren
3 A group of 7 school teachers
4 A group of 8 school gofng c'llldren (10-15years old)
5 A group of 7 pararned~cal workers worklng at the PHC
In-depth lnterv~ews were held wlth 8 marned women (25-45 years old) who had
ch~ldren Attempts were made to Interflew men However these were not successful
slnce most of the men felt that they would be unaware of the health problems of
ch~ldren Th~s could be due to the fact that ~n the culture of the village mothers were
generally respons~ble for ch~laren s health (The general response was
How wlll I
know? All those thlngs only mothers w~ll know) Care was taken to vlslt the women
when they were not very busy w~th thecr household chores so that they were relaxed
and free to respcnd Each lnterflew lasted for about 45 mlnutes All the lntervlews
were recorded on aud~o tapes w~th the consent of the respondents

(iii) Nonparticipant observation
Nonparticlpatory observation was carried out throughout the study by the lnvestlgator
and careful record~ng of the ObSe~ati~fl~ were done in the f~eld itself.
(iv) Quantitative
Based on the analysis of qualitative data, a structured questionnaire was destgned.
The questionnaire was prepared in the local language, Tamil, by the investigator and
translated into English. The English version was given to a neutral person for
retranslating into Tamil. The original and retranslated Tamil versions of the
questionnaire were compared and corrected for clanty. The questionnaire was then
pretested in the neighboring villages before being introduced in the study vtllage and
was used to collect data from randomly selected 80 women and 80 men A total sample
slze of 160 was based on logisttcal consideration, particularly slnce luring pretesting of
the questionnaire it was found that, each Interview took about 45 m~nutes (including
tlme taken for rapport butlding)
/b) Other epidemiological methods
Data on nutrlt~on, spectrum of illness and health seeklng behavior were obtained from
the follow~ng sources,-
(i) Rural area
Cross sect~onal morbidity survey
Cohort study on health issues
Records maintained by VHN and PHC
(ii) Tertiary care hospital
Out patient records

(i) Rural area
Cross scctior~al r~iorbldlty survcy
Th~s was camed out ~n chlldren studylng ~n the prlmary m~ddle and h~gh school
sectlons of the government school at Kedar The survey was conducted ~n one of the
classrooms of the school after obtalnlng pnor permission of the school pr~ncipal
Durlng each v~slto the school about 40-50 students were examlned In a week 2 to 3
vlslts were made Some children who were absent during the flrst vlslt were exam~ned
dunng subsequent vlslts In the school ~tself, or, at the sub center or at thelr res~dence
A rnlnlmum of 3 attempts were made to examlne each ch~ld The school vls~ts whre
sometimes Interrupted by inclement weather or unexpected holidays The cross
sectional morb~d~ty survey took f~fteen weeks startlng from November 1995
A detailed history of any illness suffered during the previous 2 weeks nature of rllness
type of treatment recelved school loss sustained and h~story of passing worms ~n
stools was obtalned from each chlld This was followed by a routine clinlcal
examlnatlon measurement of we~ght he~ght and tests for hear~ng and v~sual acqu~ty
The lnformat~on collected was entered on a predes~gned and pretested proforma
(Append~xl)
For measunng the~r height one of the walls of the classroom was calibrated
uslng a metallic tape
The chlldren were then made to stand agalnst the wall after
removlng thelr footwear, with their heels and buttocks touchlng the wall
They were
made to look stra~ght and the he~ght was measured to the nearest 0 5 cm
The wetght was taken to the nearest 0 5 kg after rnaklng the ch~ldren stand
erect on the weighlng machine w~thoutheir footwear

The height and weight of the chlldren were compared with the standards of affluent
Indian children (Agamal eta/., 1992) and National Center For Health Statistics, USA -
NCHS (Anonymous,l987a). The body mass index (BMI) was calculated by uslng the
formula we~ght(kg)xIOO/lhe~ght (cms)12. A BMI of c 0.13 was taken as an index of
under nutrit~on in children between 5-12 years. This value is close to that suggested by
Ramakrishnan el a1.(1992) as being applicable to children in Tamil Nadu
Visual ac~uity_ This was tested by the investigator using Snellen's chart. Those who
were found to have defective vision were screened once agaln in the f~eld by an
ophthalmologist to confirm the diagnosis.
Hearina. This was assessed uslng Rinne's test with a tuning fork of frequency 256.
Those children with defective hearing were subsequently examined by an
otorhinolaryngologist for confirmation of diagnosis. Owing to practical difficult~es
aud~ometry could not be done in the field.
Examination of other systems was done by standard clinical methods A d~agnos~s of
vltamln A deficiency was made only In the presence of both xerosls and Bitot's spots
(XIB) as per the recommendation of WHO (1976).
2 Cohort study
Considenng practical logistics, tt was designed to cover 25.0% of the total households
with children between 5-20 years. or. 100 such house holds, whichever was higher.
Uslng the census data. 100 families with children between 5-20 years of age were
randomly selected for monthly follow up for one year, for issues related to health. The
cohort was examined and interviewed by the investigator at regular Intervals. For
morbidity, the cohort was visited fortnightly and details of illness and treatment received
obtained. In order to study the variations in the dietary intake over a period of one Year,

a long~tud~nal survey was conducted Instead of a one tlme d~etary survey For th~s
purpose d~etary history was ellc~ted for each chtld by 24 hour recall dunng monthly
v~stts Thus, there were 12 0bSe~atl0nS for dtetary Intake for each ch~ld The average
tntake of nutrients was calculated for each chlld and subsequently for each age The
nutrltlve values were calculated us~ng standard methods (Anonymous1990
Swamlnathan,l992) All the lnformat~on pertatntng to morb~d~ty and dtetary Intake was
entered on a predes~gned and pretested proforma (Append~xl)
3 Records from the PHC and VHN
The average dally attendance of children between 5-15 yearsof age at the PHC was
obtatned from the records rna~ntained at the PHC for a period of 3 months (July,1996-
September,l996). However, details of illnesses could not be obtained because of poor
record~ng
The VHN maintains a good record of all tllnesses treated by her. Details of illnesses
treated by her in children between 5-15 years of age were collected every month for a
pertod of 1 year from January, 1996 to December, 1996.
3 Tertiary care hospital
Data on morbidity In school age children was collected from the tertlary care hosp~tal
(JIPMER) to get a wider perspective of the nature of illness In them. Once a week,
data Nas collected from the new outpatient case records of ch~ldren between 5-15
years of age. Thts was done for one year from June,1996 to May,1997. Care was
taken to see that data were collected equally from all week days excluding Sundays

5 3.2 Organization of date and analyses
la) Ethnographic data
From the audio tapes, the contents of the focus group discussions and in-depth
lriterviews were translated verbatim into English and transcribed. The transcr~bed data
was organized in the computer using Word Perfect version 5.1 and subsequently
analyzed using Textbase Alpha package. The data obtained by the questionnaire was
organized in a data base (d base IV) and analyzed using Ept lnfo 6 software package.
Before analyses all the entries were verified.
jbJ Other epidemioloaical data
All the data were entered on a spread sheet (Quattro Pro version 5) and the entries
ver~fied. They were subsequently wnverted into dbase IV and analyzed uslng Epi lnfo
6 software package and Quattro Pro.
LC) Statistical methods applied
Both descriptive and analytical statistical methods were employed as applicable, for the
analys~s of epidemiological data. Analytical tools were used mainly to compare the
vanous issues between girls and boys (e.g, prevalence of disorders). The various
stat~stical tests that were used were :- Chi square test; Fishets exact test; ANOVA,
Kwskal-Wallis test; Z test for large sample means, and Student's "1" test (for paired
samples and for unpaired samples w~th equal variance).
5.4 Results
The results pertaining to the issues under the aspect of health in school age children.
obtained by both ethnographic and other epidemiological methods are described in this

;ectlon For each Issue, the 0bSe~at10nS by ethnographic methods are foIl,,wc~ !I,
req(ilt~ derived by other Ppld~ml~lo~lcal methods Before PIOCPP~IIIQ !n 1111.
presentation of the results pertaining to the different Issues, the characteristics of the
school ch~ldren examlned ~n cross sectional morbldlty survey and the cohort followed
up longltudlnally are described
5.4. I Description of the chrldren in the cross sectional morbidity survey and the
cohort.
[a) School children examined in cross sectional morbid~ty survey
Out of a total of 1.881 children in school, 1,349 were available for examlnatlon The
rest could not be examined desplte a minlmum of 3 attempts to examine them The
1.349 chlldren Included 591 glrls (81 1% of all girls In the school) and 758 boys (65 3%
of all boys In the school) Chlldren from the ne~ghborlng v~tlages also attend the school
at Kedar Out of 591 girls, 80 (13 5%) and out of 758 boys, 325 (42 9%) were from
neighboring vlllages Slnce the cultural and the socloeconomlc condit~ons ~n the
nelghborln~ vlllages were slmllar to the study vlllage, ~t was assumed that ch~ldren from
outside the vlllage were comparable to the chlldren in Kedar The age and gender
d~strlbut~on of the examlned chlldren has been compared w~th that of the villagc-
chlldren between 5-15 years of age In Figure 5.1 It was observed that between 5-8
yeara of age, the proport~on of girls and boys examlned was lower than that of the
corresponding village population, in the age group 9-12 years, the proportion exam~ned
was sim~lar, and in the age group 13-15 years the proport~on of examined children was
h~gher Thls was perhaps due to the fact that in the lower age group, all the chlldren
Studying In school were from the village and the lower proportion examlned was a

eflection of the lower enrollment rate In the older age groups, there were Ch,ldren fron:
the nelghborlng vlllages also and thls perhaps was reflected In the near equal or tli(,tii-.r
proport~on of ch~ldren examlned when compared w~th the village populat~on
(b) Cohort
Thts group of chlldren Included 96 g~rls and 119 boys from 100 famllles
Six months
after startlng the study, 3 gtrls and 3 boys ranging In age from 10-17 years, were
declared as dropouts Of these, 5 (1 boy and 1 girl from the same famlly) lefl the village
to work elsewhere and 1 boy left for hlgher studles The age and gender spectflc
dlstrlbutlon of the cohort IS glven tn Table 5.9 The age and gender d~stnbut~on of the
cohort has been compared wlth that of all chlldren In the correspond~ng age group In
the vlllage ~n Figure. 5.2 It was observed that the proport~on of chlldren examlned ~n
different age groups was slm~lar to that ~n the village populat~on
5.4.2 Nutrition
(i) Ethnographic methods
Durlng the study penod, the lnvestlgator observed that the staple dlet of the villagers
was rice Cooked rice was usually taken along wlth l~qu~d concoctions Ilke, "rasam",
"samba? or "katakozhambu" made from tamannd water
Sometimes vegetable llke
drumstick, brlfljal or carrot were added Green leaves were also tncluded The other
main dlet was "koozh" or porrldge made from rag1 wh~ch was generally taken by people
who could not afford to buy rlce The key Informant observed, " When we don't have
money to buy rice, we make ragi koozh. It is quite tasty. One doesn't feel hungry

for a long time after taking koozh." It was also obn~wed that 1110 ~iiti~ke 01 1111th 1111lk
products, fnilts, eggs and meat was negligible by all sect~ons of people
People
generally cooked once a day only Dunng vlslts to the vlllage it was nottcea that all the
fam~ly members ate the same type of food Thls was also brought out in focus group
d~scussions A 35 year old woman sa~d, "We all eat the same food We don't cook
separate food for ch~ldren and for adults." Many people expressed a s~mllar oplnton
(ii) Other epidemiological methods
Details about dietary intake were obtained by 24 hour recall method once a month, for
one year from the cohort. The nutrients included calories, proteins, vitamin A, thiamine
(vitamin BI) riboflavin (vitamin B2), niacin and iron. The nutrient intake for girls and boys
are compared with the recommended dietary allowance (RDA) for each age in Tables
510 A - 5.llE. The intake of all the nutrients considered were found to be signif~cantly
less than the RDA for both girls and boys in most of the age groups (p < 0.05). As for
as the intake of calories was concerned, it was more than the RDA for g~rls at 5 years
of age. For boys in the same age, it was almost equal. In the rema~ning ages, it ranged
from about 55.0%-97.0%, lower values being found in the adolescent age group
(Figures. 3). The protein intake was almost normal up to 9 years of age after which li
became less and was around 55.0%-85.0% of the RDA (Figum 5.4). Among vltamlns,
th~amine intake was found to be equal to the RDA in a few individual in age groups in
both the genders, and In others, it was over 75.0%. The intake of other vitamins and
iron was mu& less than the RDA ranging from about 7.0% to 75.0°/o. A wide variation
was obsewed in the intake of various nutrients over a penod of one year,
Particularly with respect to vitamin A (Figures 5.5 A5.5G). The difference between the

ecommended and the actual intake of each of these nutrients was not slgnif~cantly
d~fferent between girls and boys (p > 0.05 for each of the nutrient).
{b) Nutritional status
(i) Other epidemiological methods
The nutritional status was determined by anthropometry. The height, weight and BMI of
the children examined are shown in Figures 5.65.11 The height and weight of both
g~rls and boys were less than the affluent Indians and the NCHS standards. The
difference between the study group and the groups compared was found to increase
w~th age For chlldren betweer1 5-12 years of age, nutritional status was also assessed
by the BMI. Taking 0 13 as the cut off point (Ramakrishnan, 1992), it was found that,
192 out of 352 gids (54.5%) and 253 out of 420 boys (60.2%) were under nour~shed.
No signifcant difference was observed between the genders (p > 0.05). In general, for
g~rls, the BMI remalned constant at 0.13 between 5 and 11 years of age, except at the
age of 7 years when it was 0 14
From age 11 years onwards, it showed a steady
Increase =or boys it was constant at 0.13 upto age llyears Thereafter it was 0.14
upto age 14 years and again showed an increase at 15 years of age.
5.4.3 Spectrum of illness and causes
la) fthnoqraphic methods
(i) Spectrum
Group discussions revealed a wide spectrum of illnesses that occurred in school age
children. The illnesses included fever, respiratory infection, headache, abdom~nal Pain,
diarrhea, skin infections, dental caries, jaundice, convulsions, eye problems and

qurles However, the common ailments were thought to be fever, respiratory infection,
headache and abdominal pain. Of the 160 people interviewed w~th a struciuied
questionnaire, fever was thought to be common by about 95.0%, respiratory infection
by 85.0%. headache by 80 0%. abdominal pain by 53.0% A few respondents (11 4%)
also considered scab~es and dental caries to be common in school age children.
Anemia, angular stomatitis and worm infestation were generally not perceived as
illnesses, although people were very much aware of the presence of these cond~tions in
school age children. Thls is evident from the fact that on specific questioning. 79.3%
78 1% and 61.3% of the respondents expressed that worm infestation, angular
stomatitis and anemia respectively were also common problems iii school age ch~ldren,
although they had not listed them as common health problems spontaneously. A
rnajonty (80 6%) thought that children in the primary school fell ill more often than
others Most of them (73.1%) felt that both girls and boys fell 111 with more or less equal
frequency. However, few people felt that girls fell ill more frequently when compared to
boys and a few thought the other way.
llle following are some of the statements made in group discussions:-
1. "Fever, cough and cold are common especially in rainy season" (A 30 year old
woman). Many people had a slmilar view.
2. "Cough and cold are very common. They will sit next to you and go on
coughing and you can't read" (A 12 year old boy).
3. "Between 5-7 years they fall ill. After that they become all right" (A 28 year old
woman).

(11) Causes
Change of water cold food that doesn't agree w~th the body and excessive hear are
the common causes attnbuted to vanous illnesses The varlous causes of ~llnesses as
perceived by the communlty are grven In Table 5.12 Worm rnfestat~on was not
cons~dered a dlsorder at all by the communlty In general Many people (45 0%) thought
that rlce eaters will have worms because of accumulat~on of rlce In the stomach
The following are some of the statements made ~n this regad:-
1. "Boys studying in private school fall ill mom ofien because the water is
different. That is well water. That is why they get fever, cold and fits" (A 30
year old woman In an in-depth interview).
2. "Worms are due to eating rice and ragi" (A 40 year old woman in a group
dlscuss~on).
3. "In those days they used to give purgative periodically to clean the stomach.
All the dirt will come out. Nowadays nobody cleans the stomach. That is why
rice accumulates and we get worms" (A 45 year old man in a group discussion).
4. "Sometime a child gets fever due to fear" (A 32 year old man in a group
discussion)
5. "Skin infection is due to playing in the mud" (A 30 year old woman in an in-depth
Illlolvlow)
6. " Excessive heat in the body comes out as diarrhea. If one takes lemon and
buttermilk, it will be all right" (A 40 year old woman in a group discussion).

jb) Other epidemiolo~ical methods
Data on the spectrum of illness was obtained from 4 sources namely, cross sect~onal
rnorbidlty survey, cohort study, records malnta~ned at the PHC and by the VHN, and
tertiary care hospital
(i) Cross sectional morbidity survey
This included a detailed history and cllnical examination. The results are discussed
separately for them
a History
A total of 265 out of 1,349 chiidren (19.6%) gave a hlstory of havlng suffered from
some form of illness or the other during the prevlous 2 weeks. The types of dlsorders
they had is depicted in Tables 5.13 and 5.14. The common ailo;ents reported were
fever, in 168 (12.5%) children, respiratory Infection in 90(6.7%), headache in 63 (4.7%)
and abdom~nal pain seen in 39 (2 9%) children. Diarrheal disorders, ear discharge, eye
and skln Infections were reported in less than 1.0% of children. The total number of'
dlsorders in g~rls was 162, with an average of 0.3 disorderlchild and the total number of
d~sorders In boys was 219, w~th an average of 0.3 disorderlch~ld. No slgnlflcant
dilln~oti~:~ wns ol~sorvod bolwoo~i y~rls a ~ boys ~ d olll~ar in llia avsrngo dlsordorlcli~ld
( Z = 1 64: p > 0 05) or in the prevalence of reported disorders (p > 0 05; Table 5.15).
In boys, there was not much difference in the reported prevalence of disorders In the
different age groups except headache, which was more in the 5-8 year age group,
whereas for girls, in addltion to headache, fever was also reported more In the 5-8 age
group (Tables 5.13 and 5.14).

The mean duration of fever was 3.6(i 2.8) days, respiratory infect~on 4.5(12 9) days,
abdominal pain 2.7(t 2 9) days and headache 3 3(t 2.8) days The mean durat~on of
~llness between girls and boys is compared in Table 5.16. There was no s~gnif~cant
difference between the genders (p > 0.05).
The mean school loss due to feverwas 2.1(12.7) days, respiratory infection 1 4(i 2.1)
days. abdominal paln 1.4(+2.4) days, headache l.l(i 1.8) days and diarrhea 1.5(+
2 1)days. The mean school loss due to illness between girls and boys is compared in
Table 5.17. No significant difference was observed between the genders (p > 0 05).
=, Clinical Examination
Out of 591 girls examined, only 15 (2.5%) d~d not suffer from any disorder at all, and
among boys. 25 out of 758 (3.3%) did not have any disorder. There was no significant
difference between the genders (p > 0.05) in th~s The distribution of the frequency of
d~sorden in gtds and boys is shown in Table 5.18. The disorders found on clinical
examination were classified into nutritional, infectious and others. The distribution of
these disorders is given in Tables 5.19-5.23. The total number of disorders in girls was
1,454 with an average of 2.5 disorderlchild. The total number of disorders in boys was
1,877 with an average of 2.5 disorderlchild. There was no significant difference
between the genders (2 = 1.64; p > 0. 05). However, as shown in Table 5.23,
signifiant difference was observed in some specific disorders. Anemia and worm
Infestation were significantly more prevalent in girls, while the prevalence of vitamin A
and B deficiency skin infections, cervical adenitis, periodontal diseasas and injunes
were found to be significantly higher in boys (p C 0.05).

compared to boys, the prevalence of anemla was h~gher in g~rls In all age groups and
that of worm infestatlon behveen 9-12 years of age The age prevalence pattern of
anemia and worm infestatlon was not sim~lar (Figures 5.12 and 5.13) Of those with
worm infestation, 92.0% gave a history of passing small worms, wh~ch were probably
Enfembtus and 8.0% gave a history of passlng large worms whlch were probably
Ascaris. Compared to girls, a higher prevalence of vltamin A deflciency was seen In
boys between 9-12 years of age, wh~le nboflavin deflciency was h~gher between 12-15
years of age Sk~n infection and cervlcal adenitls were more common In boys than girls
between 5-8 years. Boys were also found to have more injuries than girls (p < 0.05).
Out of a total of 42 children \with ear discharge, 7 had hearing loss (16.7%). The
prevalence of many of the infectlous disorders, in both glrls and boys was observed to
be higher in the 5-8 year age group. The prevalence of Important disorders observed
durlng school survey are given in Figure5.14.
(11) Cohort Study
Out of 96 girls and 119 boys who were selected for a 1 year follow up, only 93 glrls and
116 boys were available for complete follow up The type of d~sorders and their
frequency, observed over a penod of 1 year in the cohort are given in Tables 5.24 and
5.25. The total number of episodes of illnesses observed in girls and boys was 127
and 179 respect~vely. The average incidence of morb~dity was 1,400
episodes11,00O/year for girls and 1.500 episodes/l,OOOlyear for boys. There was no
Significant difference in the incidence of illnesses between the genders (Z = 1.64; p
0 05).The common illnesses seen were fever, respiratory infection, headache and
abdominal pain with an annual incidence of 67511,000, 26811,000 22511,000 and
17711,000 children respectively. Diarrheal disorders occurred less commonly, the

annual ~nc~dence being 6211,000 children. There was no s~gn~f~cant difference In the
incidence Of any Of Me above disorders between the genders except headache, the
~nc~dence of wh~ch was higher in boys (p < 0.05)
The mean duration of fever was 1.9(i1.64) days, respiratory infect~on 2.9(+ 0.8l)days.
headache 1.1(+0.44)days, abdominal palni.l(N.49) days and diarrheal disorders
1.4(fl.79) days. The mean duration of illness in girls and boys were compared and no
s~gnlficant difference was observed (p > 0.05, Table 5.26).
As regards seasonal distribution the overall incidence of all illnesses was h~gher In the
prernonsoon (July-September) and monsoon (October-December) months, when
compared with the postmonsoon (January-March) and summer (April-June) months
(Table 5.27)
(iii) VHN and PHC records
During the period of 1 year from January,l996 to December,l996. 578 ~nd~nduals
recelved treatment from the VHN for some illness or the other. Of these, there were 35
glrls and 52 boys between 5-15 years of age. Illness in school age children thus
accounted for 15.0% of the total illnesses treated by the VHN. The main illnesses
recorded in this group were respiratory infection in 48.6% glrls and 51.9% boys, and
diarrheal disorders observed in 40.0% girls and 30.8O/0 boys. Other illnesses seen in
them were chicken pox (n=2), myalgia (n=2), headache (n=3), injury (n=4), tooth ache
(n=l) and ear ache (n=l). No significant difference was observed in the proportion Of
girls and boys falling ill (p > 0.05). Most of the illnesses (52 episodes; 59.8%) occurred
n the premonsoon months (July- September, Table 5.27). The PHC records showed
+at out of an average daily attendance of 146 patients, 21.2% were in school age.

(iv) Tertiary care hospital
Data were collected from the outpatlent case records at weekly intervals, over a period
of 1 year There was a total of 1,443 children between 5-15 years who attended the
hospital dunng the period Of them, 693 (48.0%' were girls and 750 (52 0%) boys. The
important spectrum of illnesses seen in then: is shown in Table 5.28. Infectlous
d~sorders (32.2%) (excluding skin and ear infections), skin disorders (15.5%), worm
~nfestation (I23%) and ear d~sorders (11 0%) were the most common ailments found in
them Among the infections, respiratory tract infection was the most common
accounting for 87 5% of all infect~ons. Comparing the ailments for whlch these ch~ldren
attended the hospital, no significant difference was observed between the genders,
except for card~ovascular disorders, for which more number of boys than girls attended
the hospital (p < 0 05; Table 5.28)
5.4.4 Health seeking behavior
(a) Ethnograph~c Methods
People generally followed the allopath~c treatment, although home remed~es and
ind~genous medlclnes were also glven for some illnesses For mlnor ~llnesses most 0'
the respondents (1561160) to the structured quest~onna~re wanted to take the~r ch~ldren
to an allopath~c physlclan The remalnlng 4 lndlv~duals wanted to glve ind~genous
medic~ne Many respondents (53 1%) sa~d they would go to the local PHC and 32 5%
sa~d they would go lo a pr~vate phys~c~an For serlous illnesses all of them preferred to
take the~r ,hlldren for allopathlc treatment Most respondents (98 1%) preferred a
Private physic~an since the care was better and cure was bel~eved to be faster They

were all unanimous In saying that they would glve the same allent~on to the~r ch~ld
whether it was a girl or a boy.
The f~ll~~iflg are some of the statements made in this regard:-
1. "Who gives home remedies these days? It is only English medicine" (A 28 year
old woman in a group discussion).
2. "If my children fall sick, I take them to the VHN. She usually gives some
tablets. If it doesn't become all right I go to a doctor" (A 42 year old man In a
group discussion). Many people made a sim~lar statement.
3. "If some child has abdominal pain, we first go to the doctor and only then give
soda" (A 29 year old woman In a group discussion).
4. "There are a lot of home remedies. For cold and cough you can give "thulasi"
leaves or "musmusu" leaves" (A 36 year old woman in a group discuss~on)
5. "For jaundice only indigenous medicine will work. You have to smear him with
a paste of buffalo curds and some leaves.
Then you give him a bath.
Jaundice will go away in 3 days. He should also be given a diet without salt. If
jaundice doesn't go you can repeat the treatment" (A 40 year old Inan 111 an 11'-
depth interview).
Other Epidemioloaical Methods
Dats on this issue were obtained from the cross sectional morbidity survey and cohort
Study
It was found that 87 episodes of illnesses (33.0%) reported in the cross
sectional morbidity school survey and 139 episodes of illnesses (45.4%) reported in the
Cohort study were not given any form of treatment. Out of the various methods of
treatment available, allopathy was most commonly followed. The type of treatment

given to girls and boys are compared in Tables 5.29 and 5.30 No sign~flcant difference
was observed between the genders w~th respect to the type of treatment taken (p >
0 05).
5.5 Discussion
The health problems of school age children have not received adequate attention
mainly because they are not life threatening and the consequences of neglect are not
obv~ous ~mmediately. Many of the infectlous disorders and nutritional problems which
are prevalent among the under five's are found in school age children particularly in
developing countries (Mahajan.1992). Although, these conditions may not contribute
to the mortality among the school age children as they do among the younger children.
they do contribute significantly to the morbidity. It is important for us to Identify and also
understand some of these problems, espec~ally from the community's point of view so
that appropriate and adequate measures can be taken to reduce the morbidity in
school age children. The results derived from the current work, which included both
ethnographic and other ep~demiological methods to study the health status of school
age children, are discussed below
5.5.1 Nutrition
The study showed that the dietary Intake of school age children in Kedar was
slgnlflcantly less than the recommended values In calories, proteins, Iron, Vltamln A,
thlamlne r~btflavrn and nlacin (Tables 5.1OA5.1IE) It was observed that the ~alOne
and Protein gap between the actual intake and RDA was w~der during adolescence
FlgureS 5 3 and 5.4) Several ~nvest~gators have found that the calofle consumPtlon of

chlldren from socioeconomically backward families was inadequate In calories,
proteins, vitamins and iron (UNICEF, 1990. Aspatwar and Bapat,1995; Chaturvedi et
a1.,1996; Khan et a1,1996; Aspatwar and Bapat.l996).The nutritional inadequacy
observed in this study could be due to the low socioeconomic status of the people.
In the current study, the calorie and protein intake were about 70.0%- 80.0% of the
RDA. This is dose to the observation made by Aspatwar and Bapat (1995), who found
~t to be 60.0%-700% of RDA In them study. The mean calone consumpt~onlday In girls
In the current sl.udy was higher compared to that reported for girls from Rajasthan
(Chaturvedi el a1.,1996). This could be due to the difference in the overall
socioeconomic conditions between Tamil Nadu and Rajasthan, or, due to a difference
In the status of the girl child in these 2 states. It was also observed that the difference
between the RDA and the actual intake for iron, vitamin A, riboflavin and n~acin was
h~gher than that for thiamine. This could be due to the fact that rice, an important
source of thiam~ne was the staple diet in the study area and was taken in fairly
adequate quantities, when compared to legumes, groundnuts and green leaiy
vegetables which are good sources of iron and the other vitamins. Dietary surveys have
shown that among predominant rice eaters the average niacin intake ranges between
Sllmg/day (Anonymous,l990) which is similar to that observed in this study.
The intake of all the nutrients showed a fluctuation over a period of one year (Fig 5.5 A-
5.5G). This wuld be due to non availability of food, or non availability of money to buy
food In different seasons. However, since rice, the staple diet and the few vegetables
the villagers consume are available throughout the year, it is more likely to be due to

economlc constraints Most of the wage earners In the study village are agricultural
laborers wllll Iluctual~~ig job opportun~bes tlirougliout tlio yeor
(b) Nutritional status
Anthropometric measurements are used to assess the nutritional status of lndivlduals
Body mass index (BMI) or Quetlet's index IS an age Independent Index, which has been
found to correlate well with the nutritional status of infants and preschool children (Rao
and S1ngh.1970, Rao and Rao.1975, Raman ef a1.1989) Literature on the use of this
Index in school age children is Ihmited, although some investigators have found this to
be a sensitive index of nutnt~onal status In school age children, especially between 5-10
years of age (Babu and Chuttani,l878, Sundarem el a1.,1988. Ramakrishnan
el a1,1992) In this study, using 0.13 as the cut off po~nt for normal, ~t was observed
that 54 5% of girls and 60 2% of boys between 5-12 years were undernourished
WHO has advocated the use of a s~ngle ~nternat~onal reference data for growth
However some author~t~es felt that the reference standard der~ved from a developed
country bedme a very h~gh standard whlch was ~mposslble to reach by underprlvlleged
chlldren of develop~ng countries and therefore recommended the evolut~on of an
lndlgenous reference standard As far as lndla was concerned ~t was suggested that
the growth norms set by Agarwal based on affluent lnd~ans could be cons~dered as
lndlan reference standard (Mukher~ee.1997) In the current study ~t was observed that
tile rlledll l~olylit o11d welylil or botll y~rls and boys were less than tllo alllue~it indla~is
(Agarwal ef a1 1992) and NCHS standards (Flgures 5.6- 5 9)
The anthropometric data of the study group was compared with that reported by other
lnvestlgators In Tables 5.31A - 5.32 B. The values in the current study were found to

Le generally lower than the values reported from other rural areas. Regional variat~ons
in growth hav~ been observed in India (Chattejee and Mandal.1991. Chatterlee and
Manda1,1994). These variations could be due to economtc, dietary, social, ethn~c
(~ncludin genetic) or environmental factors. It has been shown that the growth pattern
of children was influenced by economic status: those from the LSES being more
retarded in growth than those from the USES (Pereira et a1.,1983, Rao et a1..1984;
Sundaram et a1..1988; Qamra ef a1.,1990 c; Bhasin et a1.,1990; Gupta et a1,1990;
Singh et a1.,1996) The size of a growing child is also greatly influenced by the
env~ronment The fact that better environment could bring about better growth was
shown in Canadian born Punjabi children who were taller and heavier than native bon~
Punjabis (Rao,1956).
Among environmental factors, nutrition was of greater
importance than biologic factors
The underprivileged children were constantly
exposed to severe nutritional straln and hence were retarded in growth. In this study,
the d~etary intake was found to be inadequate and could be the main contributing factor
for retarded growth, in addition to the other factors discussed above.
5.5.2 Spectrum of illness, causes and health seeking behavior
la) General morbidity
Data from four souces were analyzed in th~s study, to know about the spectrum of
ll1ness in school age children. The sources were cross sectional morbidity survey,
Wh~rt study, records ma~ntained by the VHN and PHC, and tertiary care hospital
outpatient records. The analys~s revealed nutritional and infectious d~sorders to be the
most common morbidity in school age children. In the cross sectional survey, it Was
observed that among nutritional disorders undernutrition (57.840), anemia (57.1%),

vltamln A deflc~ency (3 1%) and vltarnln B complex deflc~enc~es (32 9%) were the most
common Among lnfectlous d~sorders, worm lnfestat~on (46 4%), dental canes (27 9%)
sktn 1nfeCtlOnS (8 7%) and resplratory lnfectlon (6 0%) were common However, recall
htstory and cohort study showed fever, headache, abdornlnal pain and respiratory
lnfect~on to be the common allments In school age ch~ldren On comparing some
Important rnorb~dlty obtalned by cross sect~onal survey In this study w~th other cross
sect~onal stud~es ~t was found that there was a w~de var~at~on In the prevalence of
some of the d~sorders (Tables 5 ?A-5 28) The varlatlon could be due to any of the
following reasons (I) d~fferent d~agnost~c cr~ter~a or methods belng used by d~fferent
workers (11) seasonal varlatlon In the occurrence of d~sorders (when the studles were
carrled out) and (111) reg~onal var~atton In the prevalence of d~sorders
jb) V~tarn~n A def~ctency
The prevalence of vltarn~n A deflc~ency In the cross sect~onal study was 3 1% In a
study In Bombay Aspatwar and Bapat (1996) reported a prevalence of 77 0% and
Garg et al(1983) In Wardha reported only 10 5%
D~fferent d~agnostlc methods were
used ~n these stud~es to dlagnose wtamln A defic~ency In the current study, presence
of xerosls along w~th B~tot's spots In any one eye was used as the d~agnost~c cr~terla as
recommended by the WHO(1976) for comrnunlty survey Serum vltamln A level was
determ~ned to d~agnose vltamln A deflclency by Aspatwar and Bapat (1996) and ocular
Stgns were used by Garg et a1 (1983), who d~d not spec~fy the s~gns According to the
Crlterta la~d 3y WH0(1976), the polnt prevalence rate of more than 2 0% of XIB In the
Populat~ons at rlsk suggests a problem of publlc health rnagn~tude The magnitude of
vltamln A deflc~ency obtalned In thls survey was lndlcatlve of tt betng an Impofla 't

health problem in school age children. Dietary inadequacy could be the main reason
for the occurrence of vitamin A deficiency as it was found that most ch~ldren In this
study area mainly consumed less than 70.0 % of the RDA. Health education can play
an important part in improving the dietary intake. The vitamin A prophylaxs program
could also be extended to the school age children to overcome thls important health
problem. The higher prevalence of vitamin A defiuency recorded in boys in th~s study
was similar to that reported by other investigators (Srikantia,1989).
[c) Anemia and vitamin B complex deficiency
The prevalence of anemia (57.1%) and riboflavin deficiency (32.9%) was much higher
man those reported from other rural areas in India. Anemia in school age children
observed in the current study, is most likely to be caused by iron deficiency. Iron
defiuency anemia is quite widespread in Ind~a, the prevalence varying from 45.0% In
male adults to 70.0% or more in women and children (Anonymous,l990). Studies have
shown that the iron absorption from a habitual cereal based lndian d~et was quite low,
ranging from 2 0%-5 0%. In this study the average iron intake of chlldren was found to
be about 50 0% of the RDA. Poor dietary intake compoutided by worm lnfestalon could
be the main cause for anemla. In this study, the intake of thiamine was observed to be
relatively better than the intake of riboflavin. This could be due a better intake of nce, a
good source of thiamine, when compared to the intake of legumes and groundnuts
whlch are good sources of riboflavin and niacin. Riboflavin deficiency is widespread in
India and the prevalence of 32.9% in this study confirms the dietary inadequacy of
fiboflawn in the habitual Indian diet and the need to improve it, by health education
and/or supplementation.

jd) Worm lnfestat~on
Although the prevalence of worm lnfestatlon (46 4%) was much hlgher than that
reported from other rural areas In lndla (Table5.1), ~t was lower than that observed from
urban Madras earher (75 0% Lakshmlnarayana and Anb11,1975) There was no
assoclatlon between worm ~nfestat~on and anemla ~n th~ study Slmllar observation was
also made In a study from Japan, where no clear pattern of assoclatlon was observed
between the two (Hee-Yong,l975) Thls IS perhaps because other factors besldes
worm lnfestatlon cause anemla
je) Skln and resplratory disorders
The prevalence of common lnfectlons ~n school age chlldren l~ke skin and resplratory
~nfectlons vaned wldely In d~fferent stud~es ~n lnd~a (Table 5 1) The reasons for these
d~fferences ~n d~fferent studles are not clear However, the season In whlch the studles
have been conducted could crucially Influence thelr prevalence It IS known that the
prevalence of resplratory lnfectlons IS l~kely to be more durlng the monsoon perlod .and
that of skln 'nfectlons more In summer The dlfference observed ~n the prevalence of
these lnfectlons between the current study and the others could be due to the
d~fference In the perlod durlng whlch the morbldlty surveys were conducted
If) Goiter
The absence of gotter in this study could be due to the reason that Tamil Nadu d~d not
fall within the main goiter belt of India, although studies have shown that there were
some pockets where iodine deficiency was endemic (Pandav and Anand,1995)
Moreover, recently there has been a ban on the sale of noniodized salt in Tamil Nadu

p91d tltero is widespread use of iodized salt In the state. Hence goltor 1s not likoly to be
a public health problem in this area.
19) Deafness
The prevalence of deafness In this study was 4.5% Different invest~gators from other
parts of lndia have recorded a prevalence of deafness between 0.4% in Bihar-17 2% in
Haryana (Gupta,1989, Verma st a1.,1995) The differences in the prevalence observed
could be due to (i) different diagnostic techniques employed, (ii) real differences in the
actual prevalence or, (iii) differences in the sampling design (age and gender structure)
While audiometry was used in the studies conducted at Patiala and Haryana (Tuli el
a1,1988, Verma et a1.1995) it was not used in the current study. Although conductive
loss was observed to be an Important cause of deafness In children, only 16 7% of
those with CSOM had impaired hearing in this study, as against a hlgh prevalence of
56 8% and 61.7% of children with CSOM having impa~red hearing reported by other
lnvestlgators (Table 5.6)
The wlda var8ations in the varlous morbidity observed in different studies underscores
the need to have a standardized method to evaluate morb~dity in school age children.
lh) Government of lndia proaram
With a view to improve the health of primary school children, the Government of lndia
launched a special school health check up scheme in July, 1996 for all primary schools
In India. The paramedical workers and school teachers were trained by the PHC
med~cal officers to examine the children and look for specific morbidity. Comparison of
the results of the health checkup done in Kedar primary school by the VHN and some
school teachers, with those of the current study is shown in Table 5.33. The flndlngs

om the two stud~es dld not d~ffer w~dely although the prevalence recorded by the
paramed~cal staff was marginally lower (except for worn1 lnfestatlon and eye dlsorders)
T~IS suggests that the paramedical workers and teachers when properly tracned could
become valuable components of the School Health System (SHS)
They could be
tra~ned to look for more dlsorders lhke vlsual and heanng defects The scheme could be
extended to mcddle and hlgh school ch~ldren as well
[i) Role of qualitative studies in identifying the health problems in school aqe
- children
Although cross sectional morbidity survey showed nutritional and infectious disorders
especially anemla and worm infestation to be important morbid~ty in school age chlldren
in this study, people of the village felt that fever, headache, abdominal pain and
respiratory Infections were the most common health problems in them These were also
the most frequent morb~dity obtalned from recall history in the cross sect~onal morb~d~ty
survey and ~n the cohort study Thls dlspar~ty IS perhaps due to the etic and emlc
perspectives ~f problems 'Etlc' descnptlons are based on the categor~es created by the
investigator whrle 'emrc' descnptlons are based on the natlve categor~es of actlons
(Spradley,l979). Recall history and cohort study could also be cons~dered a seml
qualitative approach because the quest~ons were open ended and gave scope for the
respondents to think and react in their own way. Qualitative studies also showed that
People had a different perception about the cause of many of these illnesses because
If whlch medical help was not sought. For example, worm infestat~on, an important
noibidity in this study, was not considered a disorder at all by the villagers. Many Of
lem thought that it was a natural event occurring in all rice eaters. It was felt that

worms spontaneously formed In the stomach over the years as rlce gradually
accumulated In the stomach Treatment was sought only ~f ~t gave rlse to symptoms
ilke abdominal paln This suggests that there IS plenty of scope for health educatlon to
tile communlty In this regard Although the villagers were Ignorant about the ellology of
many of the dlsorders they preferred to take allopathlc treatment for most of them
There were a few exceptions llke jaundice, for whlch lnd~genous treatment was
preferred The easy avallablllty and affordablllty of allopathlc rnedlclne (for common
and minor aliments) comblned w~th the qulck rel~ef ~t gave for most common dlsorders
have made 11 popular even In rural areas However the fact that many of the allopath~c
medlclnes were obta~ned from petty shops or other unquallf~ed practltloners cannot be
Ignored The need for health educatlon for the community covering thls aspect also
requlres emphasls
It 1s thus seen that qualltatlve studles have brought out the health problems as
perce~ved by the communlty and can therefore be used as a rapid and economlc
method to ~denttfy and plan measures to tackle some of thelr health problems
However ~n the current study ~t IS also seen that some Important cond~tlons l~ke
anemla vltamln A deflclency and worm lnfestat~on that are detnmental to health were
not brought out by the qualltatlve approach Therefore, ~t 1s essential to do a cross
sedlonal survey ~n order that these Important condltlons are not mlssed Conslderlng
the cost and logtstlw lnvolved In utlllzlng the servlces of a physlc~an for this purpose 11
may not be posslble to undertake cross sectional study In every vlllage However as
observed earl~er well tralnecl paramedical workers and teachers could be utlllzed
effect~vel~ for this purpose wh~ch may be cost effectlve Bes~des health check up the
Paramedical workers and teachers could be tralned to Impart health education (as the

study has shown that the commun~ty needs to be educated on some aspects of health)
and maintain a healthy and clean environment in schools. This could help in making
several schools health promoting schools
The creation of several health promoting
schools is the goal of Global School Health Initiative (GSHI), a WHO program.

MORBIDITY PATTERN m S=
S Year oi publication
- Not available
.-........ Continued

TABLE 5.2
MORBWITT IN SCHOOL CHILDREN AS PEP\ THE REPORT OF THE STUDENT HEALTH SCHEME CELL PONDICHERRY
.......... continued
All the values are expwd as percentage of children examined
Examination done b! paramedical workers as part of the Goternment of India program of nation aide school examination of
primar). school children

1ABLE 5.3
PREVALENCE OF VITAMIN A DEFICIENCY IN DIFFERENT STUDIES IN INDIA
* Conjunctival impresrion cytology
S Year of publication
TABLE 5.4
I'I(EVAI,mN( B 01, OIINIALCAItILb IN 1)II~l~LLItWNI blLJlJlli\ IN INDIA
S Year 01 publication

TABLE 5.5
PREVALENCE OF GOITRE REPORTED IN DIFFERENT STUDIES IN INDIA
S Year of publication
TABLE 5.6
DEAFNESS ASSOCIATED WITH CHRONIC SUPPURATNE OTITIS MeDM (CSOM)
S Year td yublicnlion

I'HKVAl.H.NC'lr. O W ItIIIIIIMA I I(' IIICAIt I 1)lhllASU IN
SCHOOL AGE CHILDREN IN VARIOUS PARTS OF THE
WORLD"
* WHO (1988) Technical report wries no. 764
- Year not available

'IAULE 5.8 A
METHODS OF STUDY USED FOR DIFFERENT ISSUES ADDRESSED, AND TIME FRAME OF DATA
ml ,I.nr"rtoN
~. --
lh+l'Y.A MKI 1101)
I K N 6 l I N PHOM I0
OHHY,I(VAI'IOHH (IN MONI'IIS)
I Wl"I'RlT1ON
1 a Dietary lnlake Etbowra~h&
I
Noapart~cipmt as and when 22 AY~I'SS
I
obsen auon
I
I . Ke) ~nforniant as and when 22 AY~AI'YS h1.!'97 I
gidcmic~loeicrl
* lllclnq suncy nlollthly 12 June'96 hln)'91
1 b Nutritional
I
Cross sccl~onal one tlme 3.5 Novcmbrr'95
niorb~dt)
suncj
I[ Sl'F

METHODS OF SNDY USED FOR DIFFERENT ISSUES ADDRESSED, AND TIME FRAME OF DATA
COLLECTION
1uI:ES METllOD FREVLlENCY OF DURATION PROM 10
1 OBSERYATlONS (IN MONTIISI
Slruclurd OIIC UIIIC 3 kpumhr'94 hsrnrhr'ut
queaonnaire
coidcmiolonicd
Cross sccl~onal onc tlme 3.5 h0~mkr'95 h~id
n~orbld~l)
smc)
I rbruq'9i
Cohon stud) monthly 12 J-'96 hlq'97
Records from monlhly 12 Januwy'96 Lhcrmhrr'96
lllc VHN
ngistcr
Rc~ords rrom onc llmc 3 JuI,'% kplrmhrr'Yb
lhc PHC
rcguicr
Rccords lr0m monthl) 12 June.96 h1.1'97
care hospital
b Causes Ethnoeravhic
Focus group 6 3.5 "Id hl.)'96
I:rhn>.ry%
~I~~I~'~%IIIIIT
* InQcpth 8 3.5 bl'd h~.?'%
Frbmsy'%
lnlcmcws
Kcy ~~lforulant as a ~ whcn ~ d
22 AYRU~'~S h1.,'97
Quantilaive
Sc~ctwed one tune 3
kplmkr8% No>cmbrr'96

TABLE 5.8 A (continuetl)
$ 1 I ~ IIOI)S Olr SI0I)V IIhLI) POI1 I)IIrI'RHIIN I' ISS1IY.S Al)l)HHSSlr.l). AND 'I IhlB IIHAMI! 01' L)A lA
COLLECTION
OUSEWI'ATIONS (IN MON1 IIS) 1
BEIU\IOK
QuaIhmive
Focus group 6 3.5 hUd *l.yl%
Flblruy'%
~ X U ~ ~ I O ~ S
In-depth 8 3.5 hl~'%
Interviews
Flbru.q'%
Ke) ~nformanl as and when 22 AU@M ~.y'~i
Other
c~~dcm~ulwicaI
0 Cross sectional one time 35 Novemkr'9S !II~
niorbldly
Ptbru.r,'%
suncy
r Cohort stud) monthly 12 J-*% ~q.97

TABLE 5.8 B
ISSUES ADDRESSED BY DWFERENT METHODS
.--- -
iis1ru.8
NIIMUXHOY '11 I'Y.Ob Kl~,\l'OYIlBhlh
OBSERVATION8
OBSERVER
Y.TIINWRAPIIIC
UIKUSSIONS
Spectrum of
lllncss and lhe~r
WUSCS
Trio groups. cach
01 8 marrrcd
years 01 agc)
. Onc goupof
Emamcd mcn
with chlldrcn (25-
40 kwrs of ngc)
Agoupof7
school teachcrs
A group uf 7
plramcd~cal
workcrs
Agoupof8
school children
tcnccn I0 and 15
years 01 age
Ihl l!HVllr\\b
Spcct~um of worilcn (25-50
ill~lcss
Causes of illness
Health seehng
cluldren
.......... continued

TABLE 5.8 B (continued)
ISSUES ADDRESSED BY DIFFERENT METHODS
/ rlETIIOU 1SSt ES NI'MIIEH 01 TYPE OP HFSPONIIBNTS I
OBSERVATIONS'
OBSERVER
3 KCY INFORLIANT . ~ , lnl&e ~ l 2 ~ ~ G~rls ~n tllclr late
INrERVlEW
• Causes of tccns and early
~llness twcncles who had 1
Hcallh secklng conlplctcd then hlgh
I
behavior
school
J SO*ll~ARTIC'IPAYT VllLlgc FOpk
OUSIIHVA'I'ION
@Ll,l VTIT.4Tlll
~TRII~URBD
Q~~ESTIONN.~IRE of 160 S~sly marncd
lllncss
women (2545ycars
I
Causes of of age) w~th ch~ldren
I
1 ~llncss Slxt) marncd men I
Hcalth sccklng
khat lor
I
Young unmerr~cd
I
I
henty uomen and
I
twcnl) men
, OTIIPH
' LI~HIIIDI'I'Y SIIIUS llle vlllagc school
bl'RVXY
Spxtiumof
(.ROSS SECTIONAL Nutntlonal 1319 Chlldren study~ng In
illness
Heallh seeklng
behavlor
.......... continued

TABLE 5.8 B (continued)
ISSUES ADDRESSED BY DlFEERENT METHODS
ISSUES NllMUEW OF TYPE OF KESPONUENl'S
00SlilVATIONN
ODSSRYER
2 CWHoRTsTUDy . Spec- of 21s Randomly selcctcd from
j VIIN R~C'VHDS .
illness
Health
100 families Ular had
chldren betwccn 5-20
seehng
years of age
tehawor
spectrum 87 . Numkr of cl~~ldrcn
belucc!~ 5-15 ywrs of a&c
trwtcd bS. lhc VHN for s
period of onc )car
I
j PII('HE(QRDS . Spectrun~ of 146 Averagc dally a1tcll&i1cc
I illness of chlldren to thc PHC, /
obmncd h going
I -
IIOSPITAI.
illness
lhrough the records for 3
beluccn 5-15 yars olagc
who
aten:
hospibl for 1 ycar (data
collcacd
inlcnals lor I bear)

TABLE 5.9
ACE AND CF.NDER SPECIFIC DISTRIBUTION OF THE COHORT OF CHILDREN
ACCORDING TO SCllOOLlNC STATUS AT T11E TIME OF STUD1
AGE
CROUPS GlRLS BOYS TOTAL
(YEARS)
LNSCHOOL NOTM INSCHOOL NOTM CWS BOYS
SCHOOL
SCHOOL

TABLE 5.10 A
COMPARISON OF MEAN INTAKE OF CAC.ORIZS WITH RIjA DY

COMPARISON OF MEAN INTAKE OF PROTEIN WITH RDA BY COHORT
OF GIRLS ACCORDING TO AGE
AGE NUMBER PROTEIN
(YEARS) OF (~ms)
CI1ILDREN
HDA. IN.TAKK# S1J INTAKL AS .9 46
01. Hl) \
5 I 28 45 0 160. 7
--
Comparison of mean protein intake with RDA ( student's 't' test for
aired samples: t = -2.98 p -= 0.01)
*RDA : Rccornn~cndcd d~ctary allowa~icc
#The values are the mean ofthe values for ch~ldren In each age. the value for
each chlld being laken as the mean of 12 obsematlons for that ch~ld

TABLE 5.10 C
COMPARISON OF MEAN INTAKE OF IRON WITH RDA BY COHORT Oh'
C1HI.S AC'('OR1)ING 'TO AGE
AGE NUMBER IRON
(YEARS) OF (m~)
CHILDREN
I \ I!ITALI.:U bl) IN1 \hk..\SAVs
01, HU.\
5 I 18 4 12 Y 0 0 70.1
Comparison of mean iron intake with RDA ( student's 't' test for paired
samples: t = 9.55 p c 0.001)
*RDA . Recommended &e(ary allowance
# The values are the mean ofthe values for children In each age , the value for
each child being taken as the mean of 12 observauons for that child

TABLE 510 D
COMPARISON OF MEAN INTAKE OFVITAMIN A AND NIACIN WITH RDA BY COHORT OFCIRIJ
ACCORDING 10 ACE
AGE NUMBER VITAMIN A NIACIN
(1FARSI OF (1 Ul RDA'=ll my
C'flllDREN
-
'~mp;lriubn 01 mean vitamin A and niacin intake rilh RDA ( student's '1' lesl Lr ~~aire(l aaml~icn: vilamin A
.I1.84 1, -= lI.OOl; nlroin I - 36.23 11 < 11.001)
[he{alucs arc the mean of the values for chlldren In each age. the value lor each chtld being lake11 as the mean
''2 o~senat~ons for that ch~ld
RD4 Recornmendcd d~etpry allowance

COMPARISON OF MEAN INTAKE OF THIAMINE AND RIBOFLAVIN WITH RDA BY COHORT OF
GIRLS ACCORDING TO ACE
ACE NUMBER I1iIAMINE RIBOFLAVIN
(YEARS) OF RDA'=l.Smg RI)A'=I.Smg
CHILOREN
Ih"l4hE $1) IYIAKB .\S A % Ih'llKE )I) INIAKL 4b.4 .i
O> RDA OF MU.*
5 1 1 5 00 100.0 0 7 0 11 46.7
V 1 16 0 I g6d OX Ill - 53.3
10 I2 15 Ill I0LO OX 02 2x3
I I 7 II 0s 0 f, 0 1 - 40.0
I? 8 12 05 80.0 I (I? 40.0
I .i 4 1 6 1 I 100.7 0 X 0 0 53..i
Com[~nriaon of mcnn thiamin and riboflnrin intake with RDA (student's '1' test for prircd
aamlllcs ; thiumin t =- 2.45 11 < 0.05; ribeflnvio t = -12.49 p < 0.001)
' RDA Recommended hetar). allo~ance
# Thc r.;tl~lcs are the rncan of tl~c values Tor ch~ldrcn 111 each agc . the ral~~c
for alcll ~ l ~ berlig ~ l d 1ilhc11
;la lhc mcan or I2 obscwouons for (hat ch~ld

COMPARISON OF MEAN ~NTAKE OF CALORIES w lnl RDA
BY COHORT OF BOYS ACC'ORDING TO AGE
AGE NUMBER CAL,ORIES
(YEARS) OF (kilo calurier)
CHILDREN
HI>% IN'TAYE tl SI) INT.AYRK 9s 1 %
01, l 2248 1400 494 62.3
13 12 2340 1555 270 66.5
I 4 8 2468 1503 255 60. Y
1.5 4 2534 1721 228 6 7. Y
I6 ) ZSX(7 IT84 278 61.3
17 7 2662 107h 171 63.0
18 9 2677 1618 311 - 60. -I
19 5 2600 4 312 55. 2
20 8 2300 1650 285 72.1
Comparison of mean calorie intake with RDA ( student's 't' test for
paired samples: t = - 8.37; p -z 0.001)
* RDA : Rccommcndcd detory allowancc
# The values are the mean ofthe values for ch~ldren In each age, the
value for each chlld bang taken as the mean of 12 obsewatlons for that
chld

COMPARlSON OF MEAN INTAKE OF PROTEIN WITH KLIA BY
COHORT OF BOYS ACCORDING TO AGE
AGE NUMBER PROTEIN
(YEARS) OF (i!ms)
CHILDREN
KUA . INTAKE tt SD IHTAYL AS ,Z -/a
OF KDA
.C 1 29 47 0 - 162.1
6 6 29 3 '1 1 134.5
Comparison of mean protein intake with RDA ( student's 't' test for
paired samples: t = - 3.21; p c U.01)
* RDA Rccommendcd dietary allowance
#The values are the mean or the values for ch~ldren in cach agc , the value
for each child king taken as the mean of 12 observations for that ch~ld

TABLE 5.1 1 C
COMPARISON OF MEAN INTAKE OF IRON WITH RDA BY COHORT OF
BOYS ACCORDING TO AGE
AGE NUMBER IRON
(YEARS) OF (mu)
CHILDREN
1(1)\. INIAhkU 5V IN I AKP ,\\A
OF RI)\
5 1 18 4 19 3 0 0 - 104.9
6 6 184 I? 1 5 0 71.2
Comparison of menn irnn intake with RUA ( student's 't' test for paired
samples: t = - 2.4 p < 0.05)
1II)A Ilr, OIIIIII(III

TABLE 5.11D
COMPARISON OF MEAN INTAKP OFVITAMIN A AND NIACIN WITH RDA RY COllORT OF ROYF
A( ( ONI)IN(; 10 ALli
.-.
()EARS) OF (l,U.) RDA-12 mp
CHILDREN
RUA' IYTALF # SO INIALk A\A IYTAKEU SU INlAKEASA
Oh OF Rl)A
%OF RIM
7 1 1200 I42 0 11.8 4 I 0 0 - 34.2
1' 4 IXO!I IXX 54 10.4 59 1~ 49.2
10 9 181KI 671 846 37.4 51 20 45.0
I Ilmllrri?on of mean vilpmin A and niac.in intake with RDA ( studenl'r 'I' tesl for paired aaml)ir\: ritaslin A
' 4.5 p < 0,UlII; niacin t = -15.29 p < II.UU1)
RUA Recomn~ended kelar) allouance
ill,. , ~ lt~r; :ttr 11ar IIW~U 01 tlnr sr~lurr. I I~II~ICII III r.3~ It :$PC.. Illr

TABLE 5.11 E
- AGE NUMBER TAIAMINE RIBOFIAVLN
(YEARS) OF RDAn-I.5mg RDAn-1.5 mp
CHILDREN
INTAKE# SU INTAKE AS A Y. INTAK!$# SU INTAKE AS A h
OF RDA
OF RDA
5 1 1.8 00 - 120.0 0.9 00 - 60.0
Comparison 01 mean thiamine and riboflavin intake aith RDA ( student's 't' lest lor paired
samples: thiamine t = -2.4 p c 0.05; riboflavin t = -15.29 p < 0.001)
' RDA Recommendecl dietary allowance
U I he values are the mean of the values for cluldren In each age , the value for each cluld be~ng lakcn as
the mean of 12 obsenatrons for that cluld

TABLE 5.13
PHKVALLNC'R OF UIFQEUEN'~ 1'YI'P.S OP MORItIIBI I'Y IN Glttlh
EXAhUNED DURING CROSS SECTIONAL M0RBU)ITY SURVEY BY
RECALL HISTORY ACCORDLNG TO AGE GROUPS
DISORDER AGE GROUP IN YEARS TOTAL
5-8 9-12 13-13
oP86
FEVER 17
-266
3 1
11439
2 5
n=591
73
19.8%~ 11.7% 10.5% 12.4%
RESP. INFECTION 7 19 10 36
ABD. PAlN
8 % 7.1% 4.2% 6.1%
VW1EAL DIS 2 0 1 3
2.3% 0.0% 0.4% 0.5%
EAR DISCHARGE 0 0 1 1
0.0% 0.0% 0.4% 0.2%
SKIN INFECTION 0 1 1 2
0.0% 0.4% 0.4% 0.3%
NO DISORDER 54 199 176 429
62.8% 74.8% 73.7% 72.5%
RESP. INFECTION = Respiratory infection
ABD. PAlN I Abdominill pnin
nIAnwllQ.ar. nls. = Diarrheal diseases
# Figurer in the 2" line correspond lo % of 'n'

TABLE 5.14
PRFVAI.F.N~'P OF UIYYFWFN~I'TYPFS OF MoRnlnl rY IN BOYS
EXAMINED DURING CROSS SECIIONAL. MORBIDITY SURVEY
BY RECALL HISTORY ACCORDMG TO AGE GROUPS
-
DISORDER AGE CROUP IN YEARS TOTAL
5-8 9-12 13-15
n=116 n=JM n=JJH n=75H
FP.\ EH 16 42 37 95
13.8%~ 13.876 11.0% 12.5%
RESP. INFECTION 8 23 23 54
6976 7.6% 6. 7% 7. I %
ABD. PAIN
SKIN 1NC)I:C'IION 1 I 2 4
0.9% 0.3% 0.6% 0.576
EYE DISFASE 0 0 I 1
0.0% 0.0% 0.3% 0.1%
HESP. INFECTION = Respiratory infection
ABI,, PAIN = Abdominal pain
IPIAHRIIRAI. INS. = Dinrrhenl dincn~cs
# Figurer in the 2'd line correal~ond to "A of 'n'

TABLE 5.15
COMPARISON OF PREVALENCE OF DIFFERENT DISORDERS BETWEEN
GlRLS AND BOYS BY RECALL HISTORY
DISORDER GIRLS BOYS CHI pVALUE
n=S91 11x758 SQUARE
FEVER 73 95
12.4% 12.5% 000 > 0 05
ARI). PAIN
EAR DISC'IIARGE, I 1
0.2% 0.1% > 0 05
SKIN INFECTION 2 4 L
"YE DISEASE
0.3% 0.5% > 0 05
NO DISORDER
~nsr. r ~ t n c ~ l o ~ = Respiratory infection
ABI). PAIN = Abdominal pain
DIARRIIE,iI. DIS. = Diarrheal di~ases
* C'irl~rv.'r rtnt'l lrrf

('OMFAHISON OF O

TABLE 5.19
PREVALENCE OF NUTRITIONAL DISORDERS IN GIRLS: EXAMINED IN
THE CROSS SECTIONAL MORBIDITY SURVEY ACCORDING TO AGE
GROUP
DISORDER ACE CROUP LN YEARS TOTAL
NI'I R1 TIONAI.
SKIN D1SOROF.H
0 35 13 5 7
10.5% 13.296 5.496 9.6%
# Figures in the Zn4 line correspond to % of 'n'
TABLE 5.20
PH~,VALEN('E OF NU'IRIl'IONAL DISORDERS IN BOYS GXAMINED IN 'IIIE
CROSS SECTIONAL MORBIDITY SURVEY, ACCORDINC TO AGE GROUP
DISORDER AGE GROUP IN YEARS TOTAL
5-8 9-12 13-15
n=llh n=304 n =33H n = 7.58
ANF~IIZ 64 153 174 39 1
C. 2cU .T0..7"6 SI..Fn6 .T/.6""
# Figures in the 2"d line correspond to Yo of 'n'

TABLE 5.11
PREVA1,ENCE OF INFECTIOllS DISORDERS IN GIRIS EXAMINED IN
THE CROSS SECTIONAL MORBIDITY SURVEY ACC'ORDLNG TO ACE
CROUP
- - -
DISO-~~EH - AGE GROUP IN YEARS IOIAL
SKIN INFECTIONS 5 2 1 9 3 5
5.8% 7.9% 3.8% 5.9%
EAR INFE

TABLE 5.22
PREVALENCE OF %FECTIOUS DISORDERS M BOYS EXAMMED N
TEE CROSS SECTIONAL MORBIDITY SURVEY ACCORDMG TO ACE
GROUP
DISORDLR AGE GROUP M YEARS TOTAL
# Figurn in tbe 2' lin correspond to % of 'n'

TABLE 5.23
COMPARISON OF THE PREVALENCE OF NUTRITIONAL INFECTIOUS
AND OTHER DISORDERS BETWEEN GIRLS AND BOYS IN CROSS
SECTIONAL MORBWITY SURVEY
DISORDER GIRLS BOYS TOTAL CHI p VALUE
n- 591 n- 758 n - 1349 SQUARE
VII'AMIN A
IIRYI( 'IP.N( Y
10 32 42 6.23 c 0.05
1.7% 4.2% 3.1%
NI!TRITIONAI,
SKIN I>ISOUIlIill
57 99 156 3 46 > 0.05
9.6?6 13.116 11.676
WORM 311 315 626 15.91 < 0.001
rNFEsrAT1oN 52.6% 41.6% 46.4%
SKIN 7 5 82 117 9.44 < 0.0 I
INFKCTIONS
5.9% 10.8% 8.7%
EYE 17 I Y 36 0.06 > 0 05
INPF(TIONS
2.996 2,516 2.776
EAU 14 28 42 1.52 > 0.05
INFECTIONS
4 % 3.7% 3.1%
PER1 ODONTAL 0 5 5 * < 0.05
DISEASE 0.0% 0.7% 0.4%
2 5 7
LEPROSY 0.3% 0.7% 0.5%
t > 0.05
# Figures in the 2.d line correspond to % of 'n'
Firller's exact test
. . . . .. . . ..~~I*IIIIIIIc

TABLE 5.23 (continued)
COMPARISON OF THE PREVALENCE OF NUTRITIONAL. LNFECTIOUS
AND OTHER DISORDERS BETWF,EN ClRlS AND BOYS IN CROSS
SECTIONAL MORBlDlTY SURVEY
DISORDER ClRlS BOYS TOTAL CHI pVALUE
n -591 n -758 n= 1349 SQUARE
REFRACTIVE
I? RROR
41 37 711 2.21
6.9% 6.9% 5.8% > 0.05
DEAFNESS 34 27 61 3.20
5.8% 3.6% 4.5% > 0.05
RIIEUMATIC I 0 1 L
H& ART
DISMSE
0.2% 0.0% O.I% > 0 05
SPEECH 0 I 1 I
DISORDER
0.0% O.I% 0.1% > 0.05
# Figures in the 2* line correspond to % of 'n'
* Fisher's exact test

TABLE 5.24
ANNUAL INCIDENCE OF DIFFERENT TYPES OF DISORDERS IN
COHORT GIRLS ACCORDING TO AGE GROUP
DISORDER AGE GROUP IN YEARS TOTAL
5-10 11-15 16-20
n=31 n=37 11-25 n=93
NUMBER OF EPISODES
INCIDENCE/1,000 CHILDREN
FE) ER 22 22 2 1 65
709 594 84 698
RESP.
R 10 5 23
INFR(7 ION
ZSR 2 70 ZOO 147
lI~.Al)A~'tl~ I h 5 12
32 162 200 129
ARD. PAIN 5 6 3 14
DlARRllFAL
DIS.
SKIN
INFECTION
161 162 I20 150
3 3 2 8
96 R I RO 86
I 0 0 I
32 0 0 10

TABLE 5.25
ANNUAL INCIDENCE OF DlFFERENT TYPES OF DISORDERS IN
COHORT BOYS ACCORDING TO AGE CROUP
DISORDER AGE CROUP 1N YEARS TOTAL
NUMBER OF EPISODES
IIVCIDENCWI,OOO CHILDREN
I* El E.K
36 2 1 I9 76
972 J66 558 655
HESF IN1 IIC+I ION 14 I I R 3 3
378 244 235 284
SKlK INFECTION 1 3 0 4
27 66 0 34
CHIC'fIEN POX 0 1 0 1
0 22 0 8
1 OWl'II ACIIE 0 0 1 1
0 0 29 8
EAR ACHE 0 1 0 1
0 22 0 8
'I'otnl IIIIIII~*C(. 01 CI~I~~OIICII iIln~~~.w.(.11 - 170
Average incidence of morbiditylyear = 1.5UO episodcs/l,UUU boys
RF,SP. INFECTION = Respiratory infection
ABD. PAIN = Abdominal pain
DIAKRH~L DIS. = Diarrheal diseases
Comparison of mean number of disorders between girls and boys using
Z test for large sample means
Z value = 1.64; P r 0.05

TABLE 5.26
C'OMI'ARISON OF MEAN VURA llON OF 1)IFFERENI DISORUERS BETWEEN GIRLS ANI)
BOYS IN THE COHORT STUDY
DISORDER GIRLS BOYS
nr-18"
n-71'
htE4N SD MEAN SD 'P'VALUE pVAL17E
DllRATlON
DllIUTION
(DAYS)
(DAYS)
FF\F.X
2 0 16 I Y 16 0 10 > 0 05.
RESP IYFE(T10h 2 7 0 8 ? I 08 241 )OOF**
MI). PAIN 1 1 0 3 12 07 0 18 >O05**
DlARR1lF.Al. DIS. 2 0 10 1 0 00 3 11 7 0 05**
*ANOVA
** Kruskal Wallis test (KW)
& Numhcr of chlldrcn who llud dI%ordcl
TABLE 5.27
SEASONAL DISTRIBUTION OF EPISODES OF
DISORDERS Y
SEASON COHORT VHN
n=306 n= 87
hlOY*(NIN ') 1 20
(October-December) 30,4% U.O%
# Source uf data. One year cuhurt study and thc VHN
rrrttrdl
(0 Flgurc, In thv 2"' llnc csrt.crpn,nd (e % ef 'n'

TABLE 5.28
( OMPARISON OF SPEC'IRIIM OF DISORDERS BETWEEN GIRLS AND BOYS LN scnooi.
ACE LN A TERTLARY CARE HOSPITAL
DISORDER GIRLS BOYS TOTAL CHI pVALUE
n493 n=750 n=1.443 SQUARE
IN~ECIUI'S IIISEASES 240 225 465 3 33
34.6%* 30.0% 32.2% > 0.05
NEOPLASM
NOS INFE

TABLE 5.28 (continued)
COMPARISON OF SPECTRUM OF DISORDERS BETWEEN GIRLS AND BOYS IN SCHOOL
AGE IN A TERTIARY CARE HOSPITAL
DISORDER GIRLS BOYS TOTAL CHI pVALUE
n-693 n-750 n-1.443 SQUARE
\KIN I>IM)RI)ERS 101 122 223 0 67
14.6%~ 16.3% 15.5% > 0 05
FAR DISORDERS 88 71 159 3 51
12.7% 9.5% 11.0% > O 05
F\ Y DISORDERS 28 21 49 133
4.0% 2.8% 3.4% > 0.05
&MS = M;lsculo skclctnl
a CVS = Cardio*a~cular *>stern
# Figures in the 2'' line correspond to % of 'n'

TABLE 5.29
COMPARISON OF REPORTED SOURCES OF TREATMENT RECEIVED
BETWEEN CUUS AND BOYS IN CROSS SECTIONAL, MORBIDITY
SURVEY
TYPE OF CUlLS BOYS CHI p VALUE
TREATMENT n=lM n=159 SQUARE
PI? r'l> SiIOF 10 19 0 IY > 0 05
9. ./$6 IZ. 046
* Fisher's enact test
# Figures in the 2"d line correspond to % of 'n'

TABLE 5.30
COMPARISON OF SOURCES OF TREATMENT RECEIVED
BETWEEN GIRLS AND BOYS m COHORT STUDY
TYPE OF GlRLS BOYS CHI p VALUE
TREATMENT n%127 11-179 SQUARE
PHARMACY
34 47 0.00 > 0.05
26.8% 26.3%
PRlV,VrK
WTOR
* Fisher's exact test
$1 Number of episodes
# Figures in the 2'. line correspond to % of 'n'

TABLE 5.33
BY THE PARAMEDICAI. WORKERS1
1)lSOKDER
PKEVALENC'E AS % OF 'TOTAL CIIILDREN
EXAMINED ('n')
PARAMEDICAL REPORT
CURRENT Sl'III>Y
'n' - 376 (Primary school 'n' - 771 (612 yearn of
children)
age)
ANEMLA 41.5 56.2
WORM 62 8 52 8
INFESTATION
IWN I ~1.r AUII,~ 77 ') 14 5
KYL L)ISOKl)EHS 3.5 2.5
C '%OM 2 4 7 9
SKIN 16 9 3
INYL.CTIE>N
VITAMIN A 1.3 3.4
I>EFIC'I&NCY
' Government of India school health check up scheme in July 1996

FIGURE 5.1
Comparison of age and gender distribution of children
between 5-15 years in the cross sectional morbidity survey
with that of the village
5-8 9-12 13-15
AGE IN YEARS
e : examined in the cross sectional morbidity survey

FIGURE 5.2
Comparison of age and gender distribution of children
in the cohort and in the village
5-10 11.15 18-20
AGE IN YEARS

FIGURE 5.3
Comparison of calorle intake (as % of RDA)
between girls and boys according to age
< 100
rn
LL
0 90
IP
'0
"J 00
2
' 70
60
50
5 6 7 8 9 10 11 12 13 14 15 18 17 18 19 20
AGE IN YEARS
FIGURE 5.4
Comparison of proteln Intake (as % of RDA)
between girls and boys according to age
2 100
a
LL
0 80
'
2
W 00
70
00
50
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
AGE IN YEARS

FIGURE 5.5
Monthly variation in the intake of nutrients over a
period of one year in the cohort of children
A Calories
B Protein
"-4 ' , ; 4 i ;o 8.3 A !,
MONTH,
C Iron
D Vitamin A
' .D
11 1
0 r.
I .*
z
I
'
MONMS

FIGURE 5.5 (continued)
Monthly variation in the intake of nutrients over a
period of one year In the cohort of children
E Thlamlne
F Riboflavin
G Niacin

FIGURE 5.6
Comparlson of age specific mean heights of girls in the study
with affluent lndians and NCHS standards
170
140
130
170
110
100
L 1-
study group --+-* - affluent tndtana ----- NCHS
4 5 6 7 6 9 10 11 12 13 14 15 16 17
AGE IN YEARS
FIGURE 5.7
Comparison of age specific mean heights of boys In the study
with affluent Indians and NCHS standards

FIGURE 5.8
Comparison of age specific mean weights of girls In the study
with affluent lndians and NCHS standards
- study group + affluent ondlsn * NCHS?
I
FIGURE 5.9
Comparison of age specific mean weights of boys in the study
with affluent Indians and NCHS standards
study group - +-' affluent lndtaor - - NCHS
- -

FIGURE 5.10
Age specific body mass index (BMI) of girls
-
4 5 6 7 8 9 10 11 12 13 14 15 16
AGE IN YEARS
17
FIGURE 5.1 1
Age specific body mass index (BMI) of boys
AGE IN YEARS

Patterns of age specific prevalence of anemia and worm
infestation In girls (cross sectional morbidity survey)
UI
,r
AGE IN YEARS
I
5 6 7 8 9 1D
,
11
.
12
.
13
I
14
.
15
I
FIGURE 5.13
Patterns of age specific prevalence of anemia and worm
infestation in boys (cross sectional morbidity survey)

FIGURE 5.14
Prevalence of important disorders in children inthe cross
sectional morbidity survey
1 2 3 4 5 7 6 8 9 1 0 1 1 1 2
DISORDER
Code Dlsorder
1 Anernla
2 Worm lnfestatlon
3 V~tamln B deftctency
4 Dental carles
5 Skin Infectlon
6 Refractive error
Code D~sorder
7 Respiratory infection
8 Deafness
g Ear infection
10 Vltarnln A deficiency
I1 Eye infection
12 Injury

Education Status of School&e ~liiliiren

EDUCATION STATUS OF SCHOOL AGE CHILDREN
The progress of a natton depends to a large extent on the llteracy status and quality of
education Imparted to ~ts people Rewgnlr~ng the overall ~rnpact of education on all
splleres of developrne~il of a country, the UNICEF has declared primary educat~ol~ lor
at least 80 0% of ch~ldren as one of ~ts goals, by the year 2,000 AD (Park,1997)
Education cannot be dlvorced from the health of school age chlldren In order to have a
sense of mental and soual well belng whlch IS necessary for health, ~t IS very Important
tor all chlldren to have opttmum educat~onal opportunltles Desp~te several measures
taken by developing wuntnes to Improve the educatlonal status of chlldren. ~t has not
reached sabsfactory levels In many wuntnes (UNICEF.1995) School absentee~sm,
which 1s one of the Important factors which Influence the educatlonal status of chlldren
has no1 been addressed adequately, part~cularly wlth reference to ~ts frequency of
OCCWrence and causes Further, the cornrnunlty s polnt of wew and percept~ons on this
Important aspect of educat~on and also other factors that affect the educatronal
analnment of chrldren has not been studled, uslng ethnographic qualltatlve techniques
This 1s necessary before tak~ng steps to Improve the educat~onal status slnce ~t
enables One to formulate appropnale remedlal measures In the follow~ng section the
Important aspects pertalnlng to the educat~onal status of school age ch~ldren have been
renewed

6.2 Review of literature
6.2.1 Global Scenario
p~ Lneracy
he l~teracy level IS lower In developlng countr~es when compared to developea
wuntrles However, some developlng countr~es l~ke Ph~lipp~nes. Cuba, Argentma and
Ch~le have achieved l~teracy levels of more than 90.0% (UNICEF,1994a). The llteracy
level of some of the South East AsIan countnes IS glven In Table 6.1 In some
developlng countnes lbke Jordan. Ha~ti. Yemen. Kenya and Algena, the l~teracy level
over the last 2 decades has Increased by more than 30 0%
Of the most populous
developing nations. Chlna, Egypt, Indonesia and Mexlco are set to ach~eve the goal of
pnmary educat~on for 80.0% of the children (Chung, 1994).
(b) Dropout
About one-third of ch~ldren from the developing world fall to complete even 4 years of
education (UNICEF,1995). The percentage of gtrls and boys reachlng grade V
(standardlclass) in various reglons of the world is given In Table 6.2. The percentage of
glds reaching grade V IS lower than that of boys It has been estimated that globally 14
mlIll011 more g~rls than boys are out of school On an average, only 68 0% of g~rls reach
grade V. The percentage of girls reaching grade V In some parts of the world IS shown
In Table 6.3 The low rate of girls reaching grade V In some countnes perhaps reflects
the wew that a girl does not need an education to be a w~fe and a mother
IJUNICEF.1994 a)

6.2.2 Indian Scenario
(8) Literact
has a low llteracy rate of 52 Oofo
The female llteracy rate (37 7%) IS much lower
than the male llteracy rate (65 5% Park 1997) There has been a steady Increase In
the llteracy rate over the last several decades as shown In F~gure. 6.1 The llteracy
rate not only varied between genders but also between different states and between
rural and urban areas as shown In
Table 6 4 Among the different states In the
country Blhar Rajasthan Uttar Pradesh and Madhya Pradesh record the lowest
llteracy rates whlle Kerala records the hlghest lnd~a 1s one of the few countries where
prlmary education IS not compulsory The Increase In enrollment rate In chlldren
between the age of 6-1 1 years from about 33 0% ~n 1947 to 93 4% In 1986 reflects the
lrnportance education IS galnlng In the country (UNICEF 1990 UNICEF,1994 b) The
trend In lncreaslng enrollment over the past few years IS shown In Flgure 6.2 Although
there was an lncreaslng trend In the enrollment rate In both genders the d~fference
between them remalned more or less the same Thls 1s evldent from the fact that whlle
In boys the percentage of enrollment has Increased by about 46 0% between 1950-51
and 1986-87 in glrls ~t has Increased by about 55 0% durlng the same perlod (UNICEF.
1990) In Tam11 Nadu, the enrollment for boys and glrls In the pnrnary age group (6-11
Years) was 105 9% and 94 5% respect~vely and for those between 11-14 years of age
[he correspond~ng figures were 108 6% and 89 3% in 1995 (Anonymous 1996) Flgures
In excess Of 100 0% as shown above ~ndicate the Inherent fallacy of over-report~ng In
(he recording system

pl School Attendance
Is not enough ~f chlldren just enroll In school They also have to attend classes
regularly and complete schooling In rural areas only 41 0% of chlldren between 6 1 1
years of age were attending school compared to nearly 69046 In urban areas
(uNICEF,1990) The proportto11 of cti~ldre~i from relevant age groups, studylllg at
different levels of school~ng (pnmary and m~ddie) var~ed between the gende~ and also
between places In boys the rural attendance rates In Tam11 Nadu were 90 8% and
77 7% for pnmary and m~ddle school respectlvely and In glrls the wrrespond~ng f~gures
were 83 6% and 62 8% respectlvely There IS a lot of Inter state d~sparlty In school
attendance In children between 6-1 1 years of age ~t vaned from more than 89 0% In
Kerala to less than 33 0% In B~har Rajasthan Uttar Pradesh and Madhya Pradesh
The dlspanty In school attendance has been reported to be due to d~fferences In
economlc class, caste gender local culture and the state of awareness and tradlt~ons
It has been observed that In those ewnomlc groups where the monthly percaplta
expend~ture was less than Rs 30/month the school attendance rate was 33 2% and
where the monthly per cap~ta expend~ture was more than Rs 150, ~t was 93 1%
(UNICEF 1990)
Lc) Dropout
In India, only 52 0% of enrolled primary chlldren reach grade V wth the dropout belng
more among g~rls than boys (UNICEF.1994b) There was a w~de ~ntentate vanatlon ln
the dropout rate It vaned from 6 0% In Pond~cherry to 82 0% In Man~pur for girls and
O% In Pond~cherry to 80 0% In Man~pur for boys (UNICEF 1990) The dropout rate (%)
at the prlmary and mlddle school levels for Tam11 Nadu In the year 1995-1996 was

32.5% for girls and 15.9% for boys overall. It was 17.0% and 37.1% for girls at the
primary and middle school level respect~vely. The corresponding figures for boys were
14.9% for the primary school end 28.6% for the middle school (Anonymous, 1996).
In general, from all over lnd~a most of the dropout In chlldren occurred In the pnmaly
school (UNICEF 1890) However some lnvestlgators have observed the dropout to
Increase gradually from grade I and reach a maximum In rn~ddle and hlgh school levels.
In both glrls and boys (Nagpure 1992) There were many causes for the dropout A
study from Calcutta found poverty to be the maln cause (69 9%) of dropout followed by
~nd~fference towards school (10 4%) father's
apathy (8 4%) and separatron from famlly
(5 7% Banne~ee,l991) In another study from Maharashtra no s~gnrfrcant d~fference
between the genders was seen In the overall dropout rate though ~t Increased sharply
at 11 years of age for gtrls
Poverty and unsatisfactory scholastrc performance were
the maln reasons for dropout (Pratln~dh~ el a1
1992) In a survey by the Tam11 Nadu
government it was observed that the following were the
major causes of school
dropcult - (I) school IS unlnterestlng and class room borrng (11) poverty (111) the necess~ty
of retalnlng school golng ch~ldren at home to look after the younger ch~ldren
iAllonyrnous,l996) Conventional educat~on system IS oflen not affordable or irrelevant
allenatlng many of those ~t IS Intended to serve The hlgh dropout rate seen IS because
of the poor qual~ty and Irrelevance of the educatron system wh~ch 1s reflected In the
lnabll~ty by many of those who complete educat~on to find jobs (Vdor 1995)
Ld) Incentives
A number of Incentive schemes have been launched l~ke noon meal scheme, free
supply of uniform, text books, slates, bus passes to school golng chlldren etc. to

enrollment and reduce dropout In Tamil Nadu, children above 5 years of age
studying In schools from grade I to X are glven food supplementatton through 37 438
nutrltlous meal centers located In schools These meal centers supply 442 calor~es and
12 2gm of protelnlchtld per day at the pnmary and mlddle school level, and 511 calories
and 13 5gm of proteinlch~ldlday at the htgh school level (Anonymous 1996a) Similar
schemes are operattonal In other states also Whlle evaluating the mid-day meal
programs In 6 states considerable vartat~on In the performance indicators was
observed between the states
The enrollment status was better tn Kamataka and
Or~ssa The attendance was slgn~f~cantly h~gher and dropout rate lower In Andhra
Pradesh and Karnataka Wh~le the dropout rate was also less in Tamil Nadu Gujarat
and Kerala no difference was observed in Orlssa in the dropout rate before and after
the scheme (Anonymous l995a) In general the program functionaries and the
cornmunlty perce~ved that the program was beneficial to the children In add~t~on there
are also speclal educat~on programs that train rural girls from remote areas as primary
school teachers (Ghosh 1990)
6 3 Methodology
The following Issues were taken up
for study under the aspect of education,
Importance of educat~on, school absenteeism and school dropout Data were
collected only from the study vtllage using ethnographlc and other ep~demlologlcal
techniques Whlle the qualitative data were collected separately for Issues under
health educat~on and soclal aspects, a slngle St~ctured questionnaire was used to
collect data on all the three aspects concurrently The principles of ethnograph~c
quaiitattve methods employed were the same as that applled for health ttie deta~ls of
Which have been give11 In the chapter on health (Chapter 5 3) The data collect~on

summary tables givlng details of the issues and methods are presented in Tables 6.5A
and 0.
6.3.1 DescrlpUon of methods
fa] Ethnooraphic methods
The qualitative tools appl~ed were focus group discusstons, in-depth intemews, key
Informant Intemew, case stud~es and nonpart~upant obsewat~on In-depth lnlemem
and focus group dlscuss~ons were held In a manner slmllar to that described In the
chaDter on health
(I) Focus group d~scuss~ons and Indepth interviews
The groups selected for d~scuss~on were a group of 8 men, a group of 8 women (both
groups compnsed marned people between 25 and 50 years w~th ch~ldren In school), a
group of 7 school cti~ldren studying In m~ddle and h~gh school and a group of 7 school
teachers
Bes~des dlscuss~on w~lh these four groups. In-depth Interviews were held
w~lh 6 women all of whom Iiad school golng chlldren Attempts to lntemew men were
unsuccessful as they felt that women knew better about these Issues than them
il) Case studies
Case studies are conducted to collect comprehensive, systemat~c and In-depth
Information about cases of interest (Hudelson.1994). Case studies were also used as a
method to obtain data on causes of dropout.

Nonparticipant observation and interview
Dunng wslts to the wllage. ~t was observed that some students who were enrolled In
school had absented themselves from school These ch~ldren were InteMewed as to
the cause of not attending the school
(IV) Quantltatlve
Based on the f~nd~ngs of the qualltatlve data collected, a structured questlonnalre was
prepared and used for lntervlewlng 160 randomly selected people from the wllage As
ment~oned earller a slngle structured quest~onna~re covenng all the Issues under
health, educat~on and soclal aspects was used In the f~eld
jb) Other epidem~oloqical methods
The follow~ng methods were used to collect data on the Issues under the aspect of
educat~on -
[I) Census
Data on the l~teracy status of the village populat~on were obtained In a predes~gned and
Pretested structured form wh~le tak~ng census The ~nformat~on regarding school
dropout was collected from all ch~ldren between 5-20 years of age lrrespectlve of the
time of dropout
(11) School records
The school records were sc~tlnized for dropout for the academic year 1995-1995.
Information on the magnitude of dropout was collected using two d~fferent methods

namely school records and census It was understood that the data obta~ned by these
twc methods would be dtfferent because of the ~nherent dtfference ~n the methodology
The data from the school record was collected for the prevlous one year
whlle the
data from the census constdered dropout ln ch~ldren between 5-20 years of age
,iiespectlve of the ttme of dropout (For example a chlld who had dropped out 7 years
ago would have been tncluded for analys~s ~n the census but not ~n the school data
wt~~ch was restr~cted to orie prevtous year)
(111) Cross sect~onal survey of school ch~ldren
School ch~ldren were Intew~ewed about absentee~sm dunng school vlslts The school
was vts~ted on 10 consecuttve work~r~g days Each day one class was ws~ted ~n the
rnornlng
Dur~ng the vls~t the reason for absentee~sm was obta~ned from all those
students In that class who were absent the prevlous day but were present on that day
The data so obta~ned were entered tn a structured form
(tv) Cohort
School golng chtldren tn the selected households for the cohort study were quest~oned
for school absenteetsm
For a per~od of one year, these children were wsited once ~n
15 days and tnforrnat~on was obtatned about thelr school attendance and reasons for
absenteelsm, ~f any. The source of information was the student, sibling or parent The
dropouts ~n the cohort were a source of infonat~on for reasons for dropout.
6 3 2 Organization and analyses of date
Both ethnography and other ep~demtologtcal data were organ~zed and analyzed tn a
manner stm~lar to that descr~bed ~n the chapter on health (Chapter 5 3) Stat~st~cal tests
Were applted on the same prlnc~ples as those for Issues under the aspect of health

6.4 Results
The results pertaming to the issues under the educational status 0' school age children,
obtained by both ethnographic and other epidern~ological methods are described In this
sectlon. For each Issue, the observations by ethnographic methods are followed by
results derlved by other ep~dem~olog~cal methods
6.4. f Importance of education
la) Ethnoqraphic methods
All the partlclpants of the focus group discuss~ons and those who were inte~ewed In-
depth felt that educatlon was essent~al for both girls and boys Most of the people who
were Interviewed w~th a structured questlonnalre (1551160, 96 8%) felt that education
helped In bulld~ng the character of thelr children Some (43 1%) thought that ~t also
helped them to get jobs Most of them (70 6%) were not particular about the nature of
jobs they would lhke the~r chhldren to get end thought any job would do whereas 19 3%
wanted their children to get government jobs Almost all of them wanted thelr sons to
complete standard X Only 5 0% wanted them to stop afler the X standard, while the
rest wanted therr to study further However wlth respect to girls, 12 5% thought that
educatton up to standard Vlll would be sufflclent for them, whlle 80 0% wanted them to
study beyond standard X
The perception of the community about the extstlng school and ~ts functlon~ng hndlrectly
brought out the Importance that the community gave to educatlon The people were
generally not very happy with the government school Many (58 8%) felt that leachers
should take more interest In the students, whlle many others (56 3%) felt that the

school butldlng should be better There were some (39.4%) who thought that the
envtronmental hyg~ene should be improved. Some women (23.7%) expressed a new
that teachers were not to be blamed entlrely and that there were far too many students
for them to handle. The teachers felt that the parents should also show some interest in
thetr children's progress. The teachers were unhappy that the parents wanted the
school to do everything for the children includtng motivating them to go to school.
The followtng are some of the statements made In this regard -
1. "We go to school because it builds our character and we become good" (A 13
year old boy In a group discussion)
2. "They go to school so that they can get a job. They also get some vocational
training in school" (A 30 year old woman tn group discussion) Many expressed a
s~mtlar vtew
3. "What job will they get? We are coolies. They will also become coolies. It is
enough if they can read and learn a few words, put their sign and read a letter"
!A 36 year old womarl In an tn-depth ~nterview)
4. " The other day when I went to the school I found that two teaches were
sltt~ng and gosstplng. Where they teach? They just come, gossip and go
away. But if the students don't answer they punish them" (A 36 year old man ~n
a group dlscuss~on)
5. "Private schools are better. Government schools are hopeless" (A 30 year old
man In a group discuss~on)
6 "Teachers alone can't be blamed. Children also are difficult to control. There
are so many students. In the assembly the headmaster cannot see the last row
of students at all. How can they condition' so many of them?" (A 30 year old
Woman ln an in-depth Interview) ' The word cond~tton whtch has been adopted in
Tam11 refers to dlsc~pline
7. "The parents don't bother at all. They should also check whether the child is
doing homework properly or not ( A prtmary school leacher In a group
d~scusston)

8, "The ground is dirty. The whole school is dirty. The sheds are not all right" (A
14 year old girl In a group d~scusscon)
Other epidem~oloaical methods
The importance glven to educat~on by a community 1s reflected In the l~teracy and
enrollment rates and the proportlon of chlldren In school age attending school The
relevant data were obta~ne dunng the census
(I) L~teracy rate
The populat~on of the v~llage over 6 years of age was 2,646 out of whlch 1 660 were
literate glvlng a llteracy rate of 63 0% for the village
In the same age group, the
female lhteracy rate (51 7%) was s~gnlf~canlly less than the male l~teracy rate (74 6% p
< 0 05) The age and gender speclflc llteracy rates In the vlllage IS shown In Figure
6 3 It shows that the gender difference In the l~teracy rate was narrowing w~th t~me The
~ducat~onal status of adults over 20 years of age In the v~llage IS glven In Table 6.6
(11) Enrollment
Out of a total of 1 019 ch~ldren between 5 and 20 years of age (study age group) 107
110 5%) were not eirolled The overall educational status of ch~ldren between 5-20
years of age In the study village IS glven In Table 6 7 A s~gn~f~cant d~fference was
absewed In the enrollment rate between the genders w~th respect to the proportlon of
children enrolled w~th more boys than g~rls belng enrolled (p < 0 05) However no
difference was seen w~th respect to the proporl~on of chtldren who had completed X
Standard between the genders (p > 0 05)

(iii) Proportion of children in the relevant age group attending school
The relevant age group for the pnmary school level was taken as 5-11 years; 12-14
years for the mlddle school and 1517 years for the h~gh school levels. The proporbon
of chlldren in each group who were attending school is gtven in Figure 6.4. The
of boys studying In the pnmary and middle school was significantly more
than girls (p < 0.05) whlle there was no difference ~n the proportfon of girts and boys
studying in the hlgh school (p > 0 05)
6.4.2 School Absenteeism
(a) Causes
(I) Ethnographic methods
During group dlscuss~ons many parents felt that the common cause lor staylng away
from school was playfulness They said that the chlldren found the school bonng and
preferred to play w~th thelr fnends However, structured questtonnalre showed that only
8 8% (141160) felt that playfulness was a cause of school absenteelsm Some (30 0%)
considered illness to be an Important cause for school loss About 8 8% felt that local
functions lead to school absenteelsm whlle 4 4% felt that housework was a common
cause for absenting from school
hlng fleld vls~ts the lnvestfgator came across many chlldren who had absented
themselves from school for vanous reasons There were
53 such chlldren over a
Period of one year and on being questtoned, 33 sald they d ~d not go lo school because
Of work. 6 because of vlslts to other places, 6 because of ram. 5 because of
Playfulness, 2 because of some funct~on at home end 1 because of illness On further
9uestlonlng about the nature of work that caused them to absent from school, 24

&ildren said that they had to do odd jobs like fetchlng water, golng to the shop to buy
ylings and carry breakfast to their fatherlbrother working in the field etc. The work took
them only 0.5-1 hour However, they stayed away from school the whole day because
they were afraid of belng flned endlor punlshed for going late. The remalnlng 9 children
had to work the whole day in the field and hence couldn't go to school
he following are some of the statements made ~n thrs regard -
1. "My son doesn't go regularly. If I ask, he says that the teacher beats him
and he won't go.
He is very playful" (A 30 year old woman in a group
d~scussion) Many people expressed a slrnilar view.
2. "My daughter goes to school regularly. Last month she could not go for 7
days because she had a swelling in the leg that had to be operated" (A 36
year old woman In a group dlscuss~on)
3. "Sometimes the children go late because of some work at home like
fetching water or going to the shop" (A 28 year old woman in an ~n-depth
~ntervlew).
4. "Sometimes we have work at home and it gets late. If we go to school they
will beat us and collect fine from us" (A 13 year old boy in a group
dlscuss~on)
5. "When we go to some other village they will cry and say they also want to
come with us. We have to take them" (A 35 year old man In a group
d~scuss~on)
6. "Sometimes they complain of headache or stomach ache and don't go.
Sometimes the teacher asks for money to buy notebooks.
Bring Rs.4i-,
bring Rs.51- like that. We don't give them. So, the children don't go" (A 33
year old woman in a group d~scuss~on)
7. "Sometimes a child looses a pencil. We ask him to get one. His parents
don't get him. He doesn't write anything in class. Not only that, he
disturbs others. So, we tell him not to come to class if he doesn't have a
pencil" (A pnmary school teacher In a group discussion)

8, "During groundnut picking season, many children will not come. The whole
family will be in the field picking groundnuw (A pnrnary school teacher In a
group d~scussion).
jii) Other epidemioloaical methods
Data on this issue were obta~ned from cohort study and cross secbonal school survey.
2 Cohort Study
1" the cohort there were 54 glrls and 89 boys who were In school Dunng a one year
fo~lowup. it was observed that Inclement weather wndlbon was the maln cause of
school absenteelsm followed by ~llness, nslts outs~de the nllage, work, playfulness, and
fam~lylcommun~ty functlon (Tables 6.8 and 6.9). The gender speclflc proportlon of
school days lost by cause IS glven In F~gure 6 5 The proportlon of school days lost due
to Illness and work was more for boys when compared to glrls Adverse weather
condltlons resulted In a hlgh degree of school absence, particularly In the pnmary
school chlldren
Cross sectional school survey
Data on the causes of absenteelsm was obtalned from 226 children dunng school
wslts This Included 95 girls, of whom 28, 58 and 9 girls were from the primacy, middle
and high school levels respectively and 131 boys of whom 28, 80 and 23 boys were In
respectwe school levels. The causes of absenteeism as revealed from the school
survey are given in Tables 6.10 and 6.11. The most wmrnon cause of school
absentee~srn in girls was found to be illness, while in boys it was work. Apart from
lliness and work which were the major causes of school absence, other important
causes were local festivals and visits to other places. The propomon of chlldren with

different causes of absenteism were more or less the same for girls and boys except
for illness which was found to be significantly more In girls than in boys (p < 0.05,
Table 6.12). It was also found !'hat the maxlmum school absence occurred in the
middle school level (Figum 6.6)
jb) Mapnltude of school sbsenteeism
The magnitude of school absenteeism was determined from the cohort of ch~ldren
followed Over a one year period, 30 out of 54 (55.5%) girls and 40 out of 89 (44.9%)
boys had absented from school on one or more occasions. The total number of
episodes of school absence was 50 in g~rls and 60 in boys over a one year period. The
number of school days lost ~n girls and boys respect~vely were 90 5 and 119 5, maklng
a total of 210 days lost by 143 children in 1 year Thus the mean number of school
days lost was 1 5(?1 4) dayslch~ldlyear In girls, ~t was 1 7(+l 1) dayslchildlyear and In
boys it was 1 3(il 7) dayslchildlyear. There was no sign~ficant difference between the
genders (p > 0 05) The mean number of episode of school absenteeism per chlld
was1 6(10 6)lyear (1 740 6 eplsodelyear for girls, 1 5Kl 5 episode /year for boys) The
mean number of ep~sodes of school absence due to illness was 0 22lchlldlyear and
that due to work was 0 12/child/year The mean number of days lost due to illness was
3 2 (12 2) dayslepisode and due to work was l(i0 5) dayslepisode
LC) Seasonal Variation of school absenteeism
It was also observed in the cohort study that out of 110 episodes of school absence, 73
(66.3%) occurred during the monsoon penod, 10 (9.1%) In ttie post-monsoon, 19
(17.3%) In the pre-monsoon and 8 (7 5%) in the summer penods

6.4.3 Dropout
@) Maanitude and ~attern
Details about the magnitude of dropout for ch~ldren behveen 520 years of age were
obtained while taklng census and also fmm the village school for the year 19951996.
Analysis of the data collected at the time of census showed that in children between 5-
20 years of age. 20.9% of girls and 16.6% of boys were school dmpouts. There was no
s~gnificant difference ~n the dropout rate between glris and boys (p > 0 05)
in the vlllage school, dunng the academic year 19951996, 89 chlldren out of a total of
1 881 (4 7%) dropped out The dropout rate ~n girls was 3 7% and in boys 5 4% The
d~fference agaln was not stattstccally s~gn~flcant (p > 0 05)
The pattern of dropout w~th respect to school level In g~ris and boys as obtalned dunng
the census IS shown In F~gures 6.7 and 6 8 It is seen that for both glrls and boys.
most of the dropout occurred in the pnmary school level Analyzing the dass wise
dropout rate for the year 1995-1996 ~n the wllage school as shown in Flgure 6.9, it was
seen that the dropout occurred at an earl~er age for g~rls than for boys While the
dropout for boys occurred mostly in the m~ddle and h~gh school level. ~t was found
mostly ~n the prlrnary and the middle level of school for girls
lb) Causes
(i) Ethnographic methods
In group dtscuss~ons and dunng in-depth fntewews. ~t was felt that poor performance
and poverty were the important causes of dropout in boys and glrls. In add~tlon, girls
Were often requtred to look after younger chlldren at home Some of the participants felt

that the children themselves decide not to go to school and that there was noth~ng that
parents could do about it Most of the respondents to the SlNctured questlonnalre
(1501160, 93 8%) felt that poor performance In school was the mcst common cause for
dropout. Many (80.6%) also felt that poverty was an important cause for school
dropout About 5.0% thought that girls do not attend school after menarche. Wh~le
18 7% felt that hawng to go to work caused girls to dropout of school, only 7.5% felt
that it did so in boys
The following are some of the statements made in this regad:.
1. "My son refused to go to school after VII standard. He said 'I cannot read any
more. I am going to earn'. He is now weaving. His brother who is in the VII
standard now is also threatening to stop next year. He wants to go to Bombay
and earn" (A 37 year old woman In a group discussion).
2. "My son also refused to go to school. I don't know why. I dragged him to the
school but he ran back. I took a stick and beat him till blood stasted coming
out of his nose. He said you can beat me to death but I will not go. What can
you do?" (A 40 year old man In a group d~scussion) . A few others said that they
also had sim~lar experiences
3. "1 could not afford to send my daughter to school after the Vlll Standard.
Moreover, she had attained menarche and I thought she could stay in the
house and help her mother" (A 50 year old man in an ~n-depth ~nte~ew)
4. "My daughter did not go to school after the Ill standard. We put her in school
only at the age of 9 along with her younger brother wha was 5 years old. We
did not put her in school earlier because she had to look afler her younger
brother. She was 12 years old when she was in the Ill standard and quite
Brown up. She felt shy and just refused to go to school" (A 36 year old woman
In an In-depth internew)

C, Case Studies
Case N0.l
Dhanalakshml was a 13 year old glrl At the beg~nnlng of the study, she was studylng In
the Vlll standard In the wllage. She was one of the children who formed the cohort.
Her older marned sister was staylng wlth them and she had just delivered her second
child The sistets first child, a son, was 2 years old. Before going to school and after
retumlng from school Dhanalakshmi had to look after her nephew. She was a very
affectionate girl and fond of her nephew. She was often observed dolng her homework
and s~multaneously playlng wlth her nephew
After the third month she was not
available for follow up Her mother explained that she had gone w~th her elder slster to
her ullage to look after the chlld and would be back after a few days Dhanalakshml
returned after a month and attended school for 2 more months Meanwhile, her slster
sent word that she needed her younger s~ster's help to mlnd the baby and her parents
sent her back to her slster's ullage She never returned to the study vlllage till the erid
of the study Her parents did not seem to be affected by the fad that Dhanalakshml
had to discontinue her stud~es Her father said. "She was reading well. But what to
do? she has to help her sister also. Any way what is she going to do after
reading? She w~ll also get married and go away".
Case No. 2
This story IS that of Anandayee, a 12 year old girl, who was studying in the VI standard
at the beginning of the study In the ullage school. She was also amongst those who
formed the cohort. She was lost for follow up and dropped out of school after 6 months

ecause she was sent to her brother's house to look after hls baby as his mfe had just
glven b~rth to a chlld
(11) Other ep~dern~olog~cal rnetl~ods
Data on the causes of dropout were obta~ned from 29 girls and 24 boys who were
dropouts In the cohort The frequency of vanous causes recorded IS glven In Table
6 13 The most Important cause of dropout In girls was poverty, while ~t was poor
performance In boys It was also observed that whlle 6 g~rls dropped out because of the
need to help at home none of the boys dropped out for the same cause
6 5 D~scuss~on
tlelng an Important aspect In the overall development of a person and the country
educat~on has been extens~vely studled Quant~tat~ve data pamcularly on lhteracy rate,
school enrollment school dropout and to some extent on school absenteeism are
ava~lable mostly In the form of reports (Anonymous 1996) However aspects related to
peoples perception of educat~on and ~ts Importance as a wntnbutlng factor In dewdlng
the status of a child has not been addressed adequately Therefore, these Issues have
been addressed uslng quant~tat~vep~dem~olog~cal and, ethnograph~c techn~ques
lncorporatlng both qualltatlve and quantltat~ve approach The matn purpose of
ethnograph~c aporoach was to understand the peoples polnl of wew The ~mportance of
Pdll~at~on to a girl rli~ld 1r1 t~rr soc~al context has been d~scussed In the chapter on
social status of the g~rl cli~ld (Chapter 7 5)
6.5. f Importance of education
Ethnograph~c data revealed that almost all the v~llagers felt that educat~on was an
Important asset in Ilfe, more so for boys. Many felt that education would bulld up the

,haracter of ch~ldren and help them come up ~n llfe L~teracy level tn an area lndlrectly
reflects the ~mportance glven to educat~on ~n that area
The fact that the overall
ilteracy rate ~n the village (63 0%) was h~gher than the Tam11 Nalu rural level (54 6%)
and the nat~onal level (52 1%) showed the Importance glven to educat~on In that area
However there are other areas ~n the state and ~n the country mth h~gher l~teracy levels
(Rao el a/. 1995) School enrollment also reflects the Importance glven to education
The overall enrollment ~n the v~llage was 89 5% belng hlgher ~n boys (93 4%) than ~n
g~ds (85 5%) Thls was found to be stat~st~cally s~gn~flcant (p < 0 05) lnterest~ngly In
splte of the h~gher l~teracy rate(vrde supra) in the wllage compared to the natlonal and
state f~gures the overall enrollment rate was lower when compared to the
correspond~rig f~gures In the state (97 5% 1n1995)and the country (936% In 1987)
(UNICEF 1990 Anonymous 1996) However these d~fferences wuld be due to
d~flerentlrne per~ods arid d~ffere~it technlques used for data collection
Although at the h~gh school level the pro~nrtlon of g~rls and boys attend~ng school was
slmllar, a lower attendance rate ~n g~rls at the pnmary and mlddle school levels
reflected the early dropout ~n thern In the village school the total dmpout rates ~n the
prlrnary and m~ddle school dunng 1995-1996 were 3 6% and 5 8% respect~vely Thls
was much lower than the dropout rates ~n Tarn11 Nadu, whlch were 15 8% and 32 5%
respect~vely for prlmary and m~ddle school levels (Anonymous,l996)
As In other studles (UNICEF 1990), most of the dropout ~n girls and boys between 520
Years of age In tlie current study had occurred at the prlmary school level Analyz~ng
the Class wlse dropout pattern ~n girls and boys dur~ng the year 19951996 (Flgure 6.5)
and also the, school attendance rate pattern ~n the wllage ~t was observed that the

dropout occurred earlier for girls than for boys. This was different from a study from
Maharashtra, that showed that the dropout rate for both girls and boys were s~milar and
gradually increased with age (Nagpure,l992). The early dropout in the wrrent study
wuld be because of the need to help at home and the relatively lower importance given
to a girl's education compared to a boys education. The effect of this perception is felt
before completing the middle level education which means that those who drop out wll
do so before completing middle school The continuat~on of education at the high
school level depended primarily on the interest shown by the child. All parents who
supported a child to enter into high school education apparently gave their support
irrespective of gender, provided they wuld financially afford.
6.5.3 Causes of drop out
In this study, it was observed that among girls, poverty was the most Important cause
for dropout followed by the need to help at home and poor performance. However,
among boys, poor performance was the leading cause fnr dropout followed by poverty.
Though education in government school was free, In that there was no tuit~on fee it has
been reported that many parents were not able to meet the opportunity costs
(UNICEF,1990). The opportunity cost rn this study ( money glven to children as
Incentive to make them go to school at the rate of Rs.0 50 to Rs.1 1- per day for 2 or 3
days in a week) was only Rs.151- per year for primary school and thls could be one of
the reasons for about 80.0% of the children completing primary educat~on However,
the middle and high school level education is not free and the study revealed that the
average cost per annum for middle school education was about Rs. 5001- and for hlgh
school education Rs.754 I-, which may not be affordable by some parents. Poverty
could also result in a child being taken away from school for earning purposes.

Researchers have not been able to clearly explain how poverty at home took away a
mild from school. In a study from Karnataka, it was observed that the largest segment
of dropout occurred in the first year at school when the children were around 6 years of
age and could not have been of much labor value to the farnllles and only around one
flhh of the children who dropped out were occupied as eamtng laborers
IUNICEF,~~~~).
The lack of tnterest and poor performance ~n school seen In thls study IS slmllar to an
obsewation made by a survey from Tam11 Nadu In the survey 11 was found that the
main cause of dropout was that the chlldren d~d not ftnd the school tnterestlng, other
causes belng poverty and the need to help at home (Anonymous,l996) Poor
performance arid poverty were the maln causes of dropout ~n a study from Maharashtra
also whlle poverty was found to be the rnaln cause tn a study from Calcutta
banner)^ 1991. Pratln~dh~ et a1 1992) The poor performance IS generally reported to
be due to a large student-teacher ratlo poor qual~ty and lnappopnateness of the
education system ~n the local context That a large student-teacher ratlo was one of the
reasons for the poor performance of students was brought out In the focus group
dscuss~ons The studenl- teacher ratto In the village school was 52 4 for pnmary school
and 56 4 for rn~ddle and hlgh school whlch IS qulte hlgh In Indla, the student-teacher
ratlo has been worsening over the years It was 35 7 In 1950 and 60 5 ~n 1990
(UNICEF 1994b) In Tam11 Nadu the student-teacher ratlo was found to be 50 0 for
both prlmary and rn~ddle school and 440 for h~gh school (Anonymous 1996)
A
universal optlmum school stze w~th an optlmum student-teacher ratlo that IS appl~cable
to all regtons w~thln a country cannot be determtned (Baker,1994) It depends on the
avallabll~ty of teachers and vanous other factors In the Un~ted Klngdom the

average student teacher ratlo IS 25 0 Even In a developing country l~ke Chlle where
,ducatlon has been glven due Importance the ratlo IS 30 0-45 0 (Rodnquez 1994) In
lndla we should pertlaps atrn al hav~rlg a better student-leacher ratlo to Ilnprove the
qual~ty of education
6.5.4 Schwl Absenteeism
In the cohort study ~t was observed that school absenteelsm was not a very tmportant
factor affechng the educat~on of school chlldren Ch~ldren who attended school dld not
frequently absent themselves The mean number of days lost per ch~ld per year was
only 1 5 (+I 4) days Adverse weather condit~ons whlch Included heavy and continuous
rams dunng the monsoon was the most common cause of school absenteelsm A malor
part of the school functions from thatched sheds and does not prowde adequate
protection from ram Th~s together w~th the d~fflcult~es In traveling In the rams,
contributed s~gn~flcantly to school absenteelsm Thls can be reduced by lmprovlng the
physical ~nfrastruclure of the school
Ill health and golng to work were lhe next common causes of absenteelsm
The ill
health Included mlnor allments lhke headache fever and abdominal paln Most of the
work whlch made the chlldren stay away from school wmpnsed odd jobs l~ke fetchlng
water carrylng lunch to the fleld going to the shop, etc whtch took about half to one
hour In the mornlng Fear of pun~shment on belng late to school was a reason to absent
oneself from school the whole day. School absence due to work could perhaps be
reduced tf the att~tude of the school authont~es were more flexlble At the same time.
Parents and chlldren also should be mottvated to be more respons~ble and dtsclpl~ned
This will also reduce school absentee~srn due to other causes like vlstts outsldc the

allage, local fesbvals and funct~ons at home etc. which were found to be other common
reasons for not going to school in the current study.
~ducatronal attainment depends on parental and communlty ~nwlvemant and In the
study area there seemed to be a def~nlte need for motlvatlng and ~nvolvlng them In
order to Improve enrollment school attendance and reduce dropout Although school
absenteelsm was not very slgnlflcant, some of the causes polnt to a lack of dlsc~pllne
and mot~vahon In both the parents and the students
lmprovlng the school
~nfrastructure, mak~ng the educat~on system more su~table and meaningful In the rural
context and lnculcatlng a sense of dlsclpllne and responslb~llty In the communlty wlll
deflnltely ralse the quallty of educat~on Imparted to school ch~ldren

TABLE 6.1
LITERACY LEVEL OF SOME OF THE SOUTH
EAST ASLAN COUNTRLES #
SRI I.ANKA
MYANMAR
U Source : UNICEF lYYJa
TABLE 6.2
PERCENTAGF OF GIRL9 ANI) BOYS REACIiING GRADE V IN
VARIOUS REGIONS OF TliE WORLD #
M1I)Ul.K F,ASI & NOH1 I1 A1,HIC'A
C'EN'I'UAI. AMEKIC'A & C'AKlnBFAN
SOIVTII ASIA
X>ll'l I1 AhlF.KIC.A
#Source : UNICEF 199-l~

TABLE 6.3
PERCENTAGE OF GIRLS REACHING GRADE V IN
SOME COUNTRIES OF THE WORLD #
# Sourrc : UNICEF 199Ja
fu Figures for ho?r nut a8ailnhlc

TABLE 6.1
('OMPARISON OF 1,ITERACY RATES (-1.) IN DIFFEHEN'I STATEW
OF INDIA (IYYI CENSUS) AC'CORUING 1'0 GENDER
-- -
1'1 !R.lAll
-
hlhhlhl
4') 7
47 2
63 7
h4 1
57 1
56 5
MHNAI,%~A
.- -- . ..
# Source : Census 1991
44 3
67 2
50 0
.......... continued

TABLE 6.4 (continued)
('OMPAHISON OF 1.1 I ERAVY HA'I'ES (%) IN DIFFEREN I'SI'A'I'EM
OF LNDlA (1991 CENSUS) ACCORDING TO GENDER
# Source: Census 1991

TABLE 6.5 A
rI~ ~~IoDS OF STUDY USED FOR DIFFERENT ISSUES ADDRESSED. AND TIME FRAME OP DATA
COLLECTION
fl I\sI'RJ LIFTIIOII PRI'Ol'ENC'l Ot DURATION tHl)U T(
ORSEHVA rlons
(MONTHS)
_/
I\IPOHIAN(:&
I ,
b l l l ' ( ~ ~
(icncml ~ssucs Ethn~*rnt~hir
Qualilori~~c
Focus group 4 3.5 hlld hlsy*n
d~ci~lcctoris
I'ebm.ly%
111-dcptll 6 3 5 hlld hlny'91
~nicn
brbm.v'%
ICI,~
Kc! ~tirorn~anl as and ~ hcn ' 12 Anwt'9S hlsy'9'
Intenlea
C)uaniiffllis~
Slruclurcd one lime j SrpBrnbrr'% Rarnllbrr'9t
qucsllonnalre
I " Llleran rale Other
gidcmiolorical
I
Lnrolllnenl Dala collcctcd one umc 3 AuEY.I.~~ (Mob..'%
along u~lli census
I ll-irn
1 >!!\tNiEt.l5hl
beneral issues
Ethnoeraohic

I
TABLE 6.5 A (continued)
' USED FOR DIFFERENT ISSUES ADDRESSED. AND TIME FRAME OF DATA
COLLECTION
- lSSllES METIIOD tRPVI'FNC1 OF I>IIR\TION FUOhl TO
OIISI'R\ A1 lOhS (LION111%)
b Magnllud-2 *r
I and reasons ~~idcmi~loeical
. School runcy onc llnlc I keb-'% trbnur)'%
('ol~orl study Tudn~&htly 12 )a'% M.1'97
Schoal rccordr
cu~lilnlivr
Focus group
d~scu?s~ons
In-dcph
4
b
IIIIC~ICU~
Kc! lnfornianl
Inlcrvlcn
a? iind ahcn
~umfilatit~c
Structured
qucsttonnalrc
one time
Srptrrnbrr'%
Rorrmbrr'%

TABLE 6.5 B
ISSIIF.9 A1)DRFSSED BY DIFFERENT MEIIIODS
Ql'41JT4711*
FOl'llS I;ROI'P
8 I I)IB~IISS10YI
Itrtporlnncc or 4 A group olX
d~~cnl~on
mnrrlcd
School
women
nhscntcclsm
bclwccn 25
. S ~hml
nnd 40 yc:!rs
Jruyx,al
O~IIXC U~II~
ch~ldrct~
A group alR
marncd mcn
bcluccn 25
and 40 wrs
or age RII~
ch~ldrcn
Agmupof7
school
teachcrs
A group or7
scl10(1I
students
; 2 I* IIRI'I I1 lo~portnncc ol
6
SIY marr~cd
IVl l~RV11~WS
cducal~on aomcn tcluccn 25
• Schwl
and 40 vcars u~lli
abscnlee~sm
chlldrcn
Scliwl dropout
I J 'IONP\RII( IrI\NI . raUsCs 1 Vtllagc pplc
01lSF.KI.41 ION ANI)
INTERVIEW
school abscncc
4 h8.Y INFORMANT
IN1 ERI'IEW
educat~on
school ahscncc
Causes of drop
OUI
5 lAhl

1
TABLE 6.5 B (continued)
ISSUES ADDRESSED RY DIFFERENT METllODS
C
MBIIIOI)
YII~IIIRW 01' 'I'\ I'U C I ~
lSSlrES OIt\I(HVh.I'lONS/ WYSPONUY.N'I'S
OBSIIWVEW
~ti4NTlTATll F 160 Randomly
s~Rl'(7t;REn . lrnponancc of selected 80
I QI~~STIONNAIWF cducallon worncn and 80
School
nlcn
ahscnlcc~srn
School dropout
cducallon
(Illcracy ralc.
school
allcnd;tt~cc and
I
dropout)
2 ('KOS5 SSF('I IONAl. , (.ilUsCS of
w.llc. . ..... ..
220 School golng
W1. SIKVF.1
abscncc chtldrcn ~
I
I J C'OHORI'SI'UUY Magn~tudc or 143 School golng
scllool abscnce
ch~ldrcn
Causcs of school 143 Schwl golng
abscncc
chlldrcn
Causes of 53 Scl~ool dropout
I

TABLE 6.6
COMPARISON OF EDUCATIONAL STATUS OF FEMALES AND MALES OVER 20
YEARS OF AGE LN THE STUDY VLLLACE
EDUCATIONAL FEMALES MALES CHI pVALUE
STATUS n = 898 n=BJJ SQUARE
1" line - Number of
individuals (n,)
2.. line = n, PS % of 'n'
I2 41
CWMPLETBD CVLLECE
1.3% 4.9% 3 95 < 0.05
DROPOUT 245 362
27.3% 42.9% 14 8 < 0.001
TABLE 6.7
COMPARISON OF EDUCATIONAL STATUS OF GIRLS AND BOYS BETWEEN 5-20
YEARS OF AGE IN THE STUDY VILLAGE
EDUCATIONAL ClRLS BOYS TOTAL CHI pVALUE
STATUS n=5U n=516 n=1019 SQUARE
1" line = Number of children (a,)
2'' line - n, a% N or 'n'
DROPOIIT W 80 170
17.9% 15.516 16.606 2 53 > 0.05
NOT ENROLLED 73 34 107
14.5% 6.6 % 10.5 % 16 I8

TABLE 6.8
('OMPARISON OP CAUSKS OF SCllOOL ABSENCK IN GIRLS A I
DIFFEREM LEVELS OF SCHOOLING LN TkiB SWDY VILLAGE
(COklOR'I STUDY)
C'AIISE PRIhIAHY MIDDLE lll

TABLE 6.9
I O~ll'~%HISOY OF ('AI'FES OF S('1100L. ARSENC'C IN BOYS AT
UI~FEREN I LEVELS OF SCIIOOLINC: IN STUDY VILLAGE
(COHORT STUDY)
TOTAI. NIIbIBER OF EPISODES OF ABSENCE
1143 11-20 0-7 1140
1" line - Number ofeyia~der (nl)
2" line - nl as % of 'n"
WORK 1 1 I 5
--
9.176 5.0:; 14.376 8. 4 76
ILLNESS 4 4 I Y
12.1% 20.0?6 14.3% 15.076
AUVII.Hhl< 2 3 8 1
7 2
WFAI'I1F.H
69.8 96 40.0% 14.3% 53.3 %
VISI I'S O~"I'SlI>E 2 5 2 9
1 HE VILLAGE
6.0% 25.0% 28.5% 15.0%
SCX'IAI, 0 1 0 1
FIINC71'IONS
0.076 5.076 0.026 1.706
PlAYPllL 0 1 I 2

TABLE 6.10
COMPARISON OF CAUSES OF SCHOOL ABSENCE IN GIRL'S AT
DIFFERENT LEVELS OF SCHOOLING IN THE STUDY VILLAGE
(SCHOOL SURVEY)
CAIISE PRIMARY MIDDLE HICII TOTAI.
SCHOOL SC11001~ WtICOL.
LEVEL LEVEL LEYEL
TOTAI. NlIMBER OF EPISODES OF ABSENCE
n=ZS n= 58 n- 9 n=Y5
I" line - Numher ofcpi.oclrs (n,)
2'' line - n , as % of In'
WORK 14 I I 3 28
50.0% 19. 006 33.306 29.506
ILLNESS 9 23 4 36

TABLE 6.11
COMPARISON OF CAUSES OP SCHOOL ABSENCE IN BOYS Al' 1)lFFEWEN'I'
LEVELS 01; SCHOOLING IN THE STUDY VILLAGE
(SCHOOL SURVEY)
- .. . - .--- -
t Allhb, l'lilhl \!I)-- hlll)lll I' 111(:11 IOlhl.
s('lltn)l. s('II(~)I, S('II(H)I.
I,EVEl, LEVEL LEVEL
TOTAL N~lhlRRR OF EPISODFS OF ABSENCE
n = 28 IF 80 1~23 a= 131
ld line = Number of episodes (01)
2" line = nl u % of 'n'
WORK 17 25 7 49
60.8 % 31.2% 30.4% 37.4%

TABLE 6.12
COMPARISON OF CAllSES OF SCklOOL ABSENCE BETWEEN GIRLS AND BOYS
S('1100L SURVEY AND COHOR r STUDY :
CAUSE SCHOOL SURVEY COHORT STUDY
AllSh V( I! I)l8E 1il
AHSRNI N UllE'lo
1'IlYir' ,%S Y. 01: .n'W
l'\IISF. ASK OP 'n'
; I , IUlM 1'111 A I I K I h IlOl h I'll1 )VAI.IIY.
\(OW
-93 a-131 WllAKII n-W n-6U bVl1AIlt:
295% 374% I21 >005 100% 83% ' >005
\ !$I I S 126% 122% 001 7005 100% 150% O25 >I105
~ l rhIl)Y l TIIR
WLIAOL
#n : Total number of episodes of school absence for the group
Virher'a exact test

COMPARISON OF C'AtISES O F DUOPOIIT IN TllE C'OIIORT OF
GIRLS AND BOYS IN THE STUDY VILLAGE
CAUSE GIRLS: BOYS CHI pVALUB
81-29 11-24 SQUARE
POVERTY 13 9
44.8%' 37.5% 0 07 > 0 05
PCX>K 5 13
PERFORMANCE
17.3% 54.2% 6.42 c 0.05
POVLWI'Y dr POOR
PERFORMANCE
I
2
3.4% 8.3% : > 0 05
DOMESTIC' I1EI.F 6 0
20.7% 0.0% < 0.05
# Figure in the zmd line i s % of 'n'
Firrher's exact test

FIGURE 6.1
Literacy rates in females and males in India over the years
1901 1011 1921 1931 194, 1951 1981 1911 1981 1901
YEARS
Source : UNICEF1990

FIGURE 6.2
Primary School Enrollment of children in India over the years
55
--
: so --
10
5
-- ......."
--
....'
..'
0 -
1950-51 5556 60-61 6566 70-71 75-76 80-81 85-86 87-88
Years
Source: Unicef 1990

FIGURE 6.3
Comparison of age and gender speclfic literacy rates between
females and males In the study village
I
AGE IN YEARS
I

FIGURE 6.4
Comparison of proportion of total girls and boys from relevant
age groups studying at different school levels in the study village
Middle(l2-14yr.)
SCHOOL LEVEL
Hiph(1617p~)

FIGURE 6.5
Comparison of proportion of school absence between
glrlo and boys according to causes (cohort study)
0, 1
field : Field work
misc : Miscellaneous

FIGURE 6.6
proportion of girls and boys who had absented themselves
from school at different school levels : school survey
I
SCHOOL LEVEL

FIGURE 6.7
Dropout pattern in glrls (5-20years) in the study village
according to school level*
FIGURE 6.8
Dropout pattern in boys (5-20years) in the study village
according to school level*
* Data collected at the time of village census

FIGURE 6.9
Comparison of dropout rates between girls and boys
in different grade8 In school*
16
1.
Y)
6 12-
m
0
5 io-
e .,:
'\ ... /
z-
, ...'
...I
,...
0- ,
I 2 3 4 1 8 7 8 0
GRADE IN SCHOOL
- , , . .. . boys
Source : School record for the year 1995-1 996

SOCIAL STATUS OF SCHOOL AGE CHILDREN
7 1 Introduction
11 IS important to have a hlgh soclal status ~n order to have a sense of soc~al well be~ng
and d~gnlty A hlgh soclal status for children entails them the nght to have opt~mum
nutntlon and health care, educat~on and freedom from abuse and explo~tat~on These
three aspects are linked wlth the ewnomlc status of a fam~ly, community and also the
country For obvlous reasons the soc~al status of chlldren in the develop~ng countnes 1s
far from satisfactory It IS also known that ~n many develop~ng countnes gender
d~scnm~natlon very much lowers the status of the g~rl ch~ld (Oduntan 1995) Although
extensive l~terature 1s available on the vanous Issues concemlng the g~rt chlld the
revlew In the current study focuses malnly on the health, educat~on and soc~al status
espec~ally of the school aged glri keeplng ~n vlew the spec~f~c objectives of the study
(Chapter 2)
7.2 Review of literature
7.2.1 Global Scenerio
la) Gender preference in having children
Many countnes all over the world hold sons In hrgh esteem Sons are needed to cany
on the famlly Ilneage, to perform rel~g~ous ntuals and to prov~de ewnornlc secunty for
their parents In old age ~n some of the countries lhke Paklstan Nepal Bangladesh
Korea and Syna, there 1s a strong preference for sons However. ~n many developed

countnes and In some develop~ng countnes llke Phlllpplnes, Jamalca and Venezuela
the preference for sons 1s not very strong (Oduntan,i995) The reasons for thls attltude
are not dearly known, although tradlbons and culture play an Important role
jb) Nutrition, health care and the airl child
In developed countnes, the mortailty In ch~ldren IS generally hlgher In males than In
females In all age groups from birth Thls IS because of the Inherent suscepbb~l~ty of the
male chlldren to succumb to illnesses for unknown reasons as there IS no
discnmlnatlon In the health care glven (Oduntan.1995) On the other hand, In
developlng countnes llke Nepal, Bangladesh, Pakistan. Snlanka, Syna, Jordan, Korea
and Egypt the mortality In Infants and chlldren was reported to be h~gher In females
than In males (Oduntan.1995) Thls was d~rectly or lndlrectly associated wlth the
nutnt~onal status of the glrl chlld thereby showlng that they suffered from a greater
degree of malnutntlon than boys In many developlng countnes, glrls have less food,
madequate health care and educatlon, and mincmal personal care and protect~on A
study In Bangladesh showed, that boys under 5 years of age were given 16 0% more
food than girls (Wallace,1995) It was also observed In another study, again from
Bangladesh, that 14 4% of female chlldren were severely malnounshed as against
5 1% of male chlldren and the male health care ut~l~zahon rate was 66 0% hlgher than
females in the same place (Okojle,1994)
Education and the girl child
Gender lnequal~ty IS evldent ~n many aspects of llfe lnequal~ty Irl educatlon IS
Particularly Important because ~t undermines the stwggle for equallty ~n almost all other
flelds Education for all has been taken seriously only since the 1950's and there IS a

tremendous Increase in the enrollment rate to ach~eve the goal of "Educat~on for all by
2000 AD" Despite thls. In some of the developing wuntnes l~ke Afghantsten, Nepal,
Bhutan, Pakistan, Bangladesh, Nigena and Morocw, the female l~teracy IS only half of
male literacy (UNICEF 1995) On an average, globally, only 68 0% of the girls who are
enrolled ~n school reach grade V In developed countnes, the f~gures are between
94 0%-100 09'0, whlle In develop~ng wuntnes ~t IS much lower, ranging from 40 0%-
83 0% Snlanka IS the only develop~ng country ~n Asla, where 95 0% of the girls who
are enrolled ~n school reach grade V In our nelghbonng countnes of Bhutan, Pakistan,
and Bangladesh, the figures are 11 0%, 280% and 450% respect~vely (UNICEF
1994a)
7 2.2 Indian Scenario
[a) Gender preference in having children
In general, there IS a broad concern for the status of the g~rl ch~ld In lnd~a There IS a
des~re to have at least one son ~n the fam~ly, though not to the same extent ~n all parts
of the wuntry Over the years, wth a tendency to l~m~t the fam~ly slze, there has been
an Increase in arnn~ocentes~s and abohon of female fetus
In 1984, a survey ln
Bombay revealed that out of 8,000 abortions reported only one was a male and In one
year about 40,000 female fetus were aborted (Mukher)ee,l991) The sex ratlo (number
Of females for every thousand males) In India (1991 census) is 927 (Park,1997)
However a heterogene~ty is observed In the sex ratlo, wth some states rep0rtlng a
h~gher rabo than others Kerala IS the only state ~n lnd~a w~th a sex ratto of 1,040
Andhra Pradesh, Karnataka. Tam11 Nadu and Hlmachal Pradesh report a sex ratlo
between 950 and 1,000, and the other stales, below 950 Haryana records the lowest

sex ratio of 874 (Subrahmanyam and Rao,1995) The relatively h~gh sex ratio in Kerala
likely to be due to the higher status of the girl child related to the matrilineal soc~ety
prevailing In the locality apart from the high literacy rate.
(b) Nutntion, health care and the ~ ~ child r l
Female children are generally glven Inadequate nutrition and health care
Stud~es
have shown that girts were breast fed for a shorter penod and d~scnm~natton was
shown between genders In glvlrrg hlgh nutnt~on or commercially available costly foods
nch In fat and milk (Ghosh 1990) The energy and proteln Intake of glrls was less than
boys at all ages and the difference was w~der In the adolescent penod (UNICEF.1990)
V~tamln A and Iron Intake among girls was also less than boys (UNICEF,1990) Thls
adversely affected the health status of g~rls A h~gher ratlo of female malnutr~t~on
espec~ally of the severe grade has been reported (Mukheqee,l991) A study In Punjab
compared prlwleged and under pnvlleged groups and found that 24 0% of females In
the former and 74 0% In the latter group were malnourished The percentage of
malnourished males In the two groups were 140% and 670°/o respe~tlvely
(Ghosh.1990)
In a study from Karnataka the proportion of malnourished glds was
found to be h~gher than that of boys (Khad~ el a1,1996) The prevalence of anemla
amongst glrls ranged from 18 0% In Madras to 95 0% In Calcutta (Mukheqee,l991) On
the other hand some stud~es have shown that there was no nutnt~onal blas agalnst the
glrls and that the~r food intake was comparable, and In some places even better than
that of boys (Brahniam ef a1,1988 Rao,1989, Subrahmanyam and Rao 1995)
chlldren remaln deprived of adequate access to baslc health care A recent
analYSls of med~cal contact rates across age and sex groups, revealed that female

children had lower contact rates than all other demographic groups tncludtng adult
females A study carried out in Ludhiana revealed the followng (UNICEF,1994b)-
. Out of 20,407 children who attended the outpattent department. 65.2% were boys
and the rest (34 890) were girls
Out of 3,773 children adm~ned In hospital. 83 5% were boys and only 16.5%
were girls
. Out of the ch~ldren admitted, the proportion of female children dying exceeded
that of male children.
In another study from the same place it was shown that males had a lower mortality
than females after the first month of llfe (Pebley and Amin.1991). Preferential
hospitalization of boys in the ratio of 60:40 was reported from a study In Bihar
(Snvastava and Nayak.1995) The male: female hosp~talization ratio vaned from 2:l to
1 3 1, the latter being malnly from South India (Ghosh,1986). The health care glven to
girls was found to be better in South lnd~a Basu (1989) observed that the probabtlily of
surv~val for girls was much lower than that of boys in the districts of Utlar Pradesh,
whlle ~t was roughly equal for gtrls and boys in Tamil Nadu. A survey from Pune
revealed that sisters recelved equal treatment as compared to their brothers with
respect to nutrit~on and health care (Kanrtkar,l996). However, a study from Salem
d~stnct In Tarn11 Nadu showed that 90.0% of the low and 25.0% of middle income
famlltes showed
btas In glving medical attention to daughters, practictng self
rrled~caliutt for dauyhle~s atid hospital atletittoll lor sons (Satnantaray and Jerla.lY9b).
though nutnt~onally the girls were better than boys Overall, the gender discnm~nation
In health care was higher in the Northern stales than the Southern states Of
India, and
over the years thts dlscrtm~natory practice appears to be on the decllne (SdvaStava and
Nayak 1995)

jcl Education and the g~rl child
A g~rls educat~on faces a number of economlc cultural sxlal and psycholog~cal
barriers especially ~n the context of rural lndla The female l~leracy rate IS 37 7% as
aga~nst the male llteracy of 65 5% (Park 1997)
The percentape of enrollment In
pnmary and m~ddle school for girls IS
79 9% and 35 6% respedlvely and the
conespondlng f~gures for males are 106 4% and 60 6% (UNICEF,1990) It has been
estimated that of all the g~rls enrolled only 58 0% reach grade V in India agalnst a
global average of 68 0% (UNICEF 1994b)
In all the states ~n India includ~rig Kerala, girls had a lower attendance rate than boys.
1 tie d~ffererice between the attendance rate of g~rls and boys was reported to be very
w~de In some states l~ke Uttar Pradesh, Bihar and Rajasthan The lowest difference was
reported frorn Kerala (UNICEF.1990). A survey of teenage girls in Pune showed that
g~rls received almost equal educational opportunities as boys (Kanitkar, 1996)
However, the results of the study cannot be generalized particularly since. ~t was
conducted in a populat~on of middle and high income status, and the sample slze was
also low
llle dropout rate was also very h~gh In g~rls particularly In those from rural areas In
Rajasthan the dropout rate In girls was as h~gh as 57 O%(UNICEF,1990) In rural lnd~a
girls who were l~kely to be withdrawn from school would belong to famllles wlth little or
no land resources These chlldren joln the unorganized chlld labor force Work force
Dartlc~patlon rate for girls ~n the age group 11-13 years was h~gher than that of boys In
both rural and urban areas Cornpanson of the work partlclpat~on rate of male and

female ch~ldren showed that between 1971 and 1981, there was an Increase In the
case of g~rls compared to boys (UNICEF,1990)
(d) Influence of menarche on the air1 child
The g~rls In rural areas are not helped by the educat~on they recelve to comprehend the
phys~cal and hormonal changes that occur w~th puberty The self perception of a
menstruating glrl IS one of ~mpunty She IS often restricted from entenng the kltchen
The parents are equally Ignorant and are more concerned about the secunty of the~r
daughters Thls att~tude leads to a severe restnctlon of her movements outs~de the
house and often results In school dropout (UNICEF,1990)
le) Marnaae
In the early part of thls century, g~ds got mamed In thew early teens Thls was perhaps
due to the fact that parents wanted to reduce the~r burden of hawng to pronde soclal
securlty to a glrl The other reason for thls could be that early marnage prowded a
longer chlld beanng penod The mean age at marnage at the turn of the century was
13 0 years It had moved to 18 3 years by 1981 (UNICEF,1990) However, there was a
w~de Inter and ~ntra state vanatlon
In states l~ke B~har, Rajasthan and Madhya
Pradesh, the mean age of rnamage was much below the nat~onal average of 16 7
years (Vlr.1990, Gopalan1993). W~th a deslre and also the need to have a small
farn~ly, the mean age at marnage IS also lncreaslng In 1981. 7 0% of girls In the age
group 10-14 years and 43 0% In the age group 15-19 years were mamed In 1987-88.
these f~gures were around 4 0% and 37 0% respect~vely (UNICEF.1990) It was
observed that gender b~as was greater In areas where the economlc potentla1 of
females was low
The h~gher cost lncuned In marrytng off g~rls ~n the North and

~~flh-We~t reglons Of the country was also responsible for the low economlc status
,nached to females in these areas. Reciprocity and bride wealth which were common
in the South enhanced the value of women in these areas (Bardhan,l988) The extent
and quality of gender dlscnmination are known to vary from place to place even wthln a
small geograph~cal area. Therefore, one has to be cautious ~n generailzing such
lnformat~on (Sen and Sengupta. 1983).
7 3 Methodology
As mentioned earller (Chapter 1 Introduction) soclal context for the purpose of this
study considered school age chtldren ~n thew home mllleu The Issues that were
considered were gender preferecce ~n hawng chlldren by the community nutrltlon and
health care gtven to them Importance glven to the~r educat~on acttv~ty pattern of
children ~n thetr dally llfe menarche and ~ts lmpllcatlon on the glrl chlld and the
cornnlurllty s attltude towards the mamage of a chid These Issues were addressed to
bring out the drfferences ~n the soctal status between glrls and boys
The actlvtty
pattern tn thls study referred to analysls of actiwtles that reflected the soclal status of
chlldren In thew home context Data on the above Issues were collected by both
ethnographlc and otner ep~dem~ologlcal methods The methods relevant to vanous
Issues and the Issues addressed by dlfferenl methods are glven ~n Tables 7 ?A-7 1C
7.3.1 Description of methods
la) Ethnoqraphic methods
The detatls of ethnographlc methods have already been descnbed In the chapter on
tlealth (Chapter 5 3) 1 l ~e method applled here was malnly ln-depth lnte~tew~, slnce it

was felt that more information could be obtained on sensitive issues like gender
preference In children and status of the girl child in the family by ~nte~ewing
In addit~on, focus gmup discussions, a case study and nonpartiupant
obse~at~on were other sourws of information.
(I) Indepth ~nterv~ews and focus group d~scuss~ons
Indepth tnterv~ews were held wth 8 women and 2 men only More men could not be
lnterv~ewed because they felt shy to express thelr wews to a female lnvestlgator
Further many felt that these Issues could be better d~scussed only wth women Out of
the 8 women, 6 wfre mamed and had ch~ldren and 2 were unmarned young g~rls
around 20 years of age Both the men were mamed and had ch~ldren The age of the
rnamed women ranged from 23-40 years The men were about 30 and 35 years old
Focus group discuss~ons were held w~th 4 groups One was a group of 8 mamed
women In the age range of 2545 years w~th ch~ldren The other was a group of 9
mamed men w~th ch~ldren They were all In the age range of 2550 years except one
man who was 70 years old One group d~scuss~on each was held wth groups of 10
adolescent girls and boys who were In school The In-depth lntarwews and focus group
d~scuss~ons were conducted ~n a manner slmllar to that descnbed under the
methodology In the chapter on health (Chapter 5 3) Structured 0bseNatl0n f0c~Slng
on some Issues lhke actlwty pattern and d~et glven to a child was also made dunng vlslts
to the wllage
(ti) Quantitative
Based on the results of the analysis of the qualitative data, a structured questionnaire
was developed and distributed to randomly selected 80 women and 80 men from the

~llage The details of preparing the questlonnarre and the composlt~on of people
~ntew~ewed have already been described !n the chapter on health (Chapter 5 3) The
same lndlvlduals were lnterv~ewed on soc~al Issues uslng a slngle questlonnalre
p) Other ep~demlolo~~cal rnetliods
~ost of the data on the lssues pertalnlng to he sowal context was obtalned from the
study nilage
However, In order to study the attitude of the parents In glwng health
care lo the~r chlldren, add~t~onal data were collected from a teNary hospital (JIPMER)
and Government Chest Cllnlc, Pondlcheny, for reasons already glven In the chapter on
overwew of study des~gn (Chapter 3) Data on care In acute ~llness were collected from
the tertlary care hosp~tal, and chron~c illness from both the tert~ary care hosp~tal and
Chest Cllnlc Care was taken to see that the data were obtalned from patlents from
mral areas and w~th a background slmllar to that of the study wllage The methodology
adopted for the rural as well as the urban areas IS bnefly descnbed below -
(I) Rural area
a Census
Whlle tak~ng census of the study wllage relevant lnformabon perta~nlng to the soclal
lssues llke ~mmunlzatlon Status (health care), age of menarche, age of mamage and
flrst ch~ld blrth was obtalned for chlldren between 520 years of age The deta~ls were
entered on a stmctured form
3 Cohort
Data on actlvlty pattern was obtalned from the cohort that was selected for studles On
morb~d~ty, d~et and school absenteeism These chlldren were ws~ted once a month and

detalls of the~r actlv~ties In the previous 24 hours were obta~ned and entered on a
structured format
The Important actlvltles focused were tlme spent on sleep,
housework attend~ng to personal care eatlng, study~ng at home and In extra coachlng
dasses on payment (tult~on) do~ng outs~de work and partlupat~ng ~n Income generating
work
(ii) Urban area
3 Tertiary care hosp~tal (JIPMER ), Pond~chemy
Acute illness
Data were collected from parents of g~rls and boys adm~ned ~n the ped~atnc ward w~th
an acute ~llness dunng the penod August, 1995-October 1995 These ch~ldren were
selected In such a way that they ha~led from rural areas s~m~lar to the study wllage The
girls and boys were matched In socioeconomic status, the nature of ~llness, farn~ly slze,
educat~onalevel of parents and other factors that could Influence the health care
glven Deta~ls about the treatment glven to the ch~ldren from the time of onset of the
f~rst symptom t~ll they got adm~tted In the ternary care hosp~tal were obta~ned and
entered In a structured form
Chronic illness
Detalls of follow up and treatment glven to children w~th cerebral palsy were obta~ned
from the case records of pat~ents who had attended JIPMER hospltal for treatment
These were selected from the case records of ch~ldren who had reported to the
OCcupat~onal therapy department of the hosp~tal between January.1994 and

fJecemberI994 They were selected In such a way that the duration and severity of
illness in both the genders matched
5 Government Chest Clinic Pondicherry
Details of treatment glven to children below 15 years of age during the penod
January,l994-December,1994 at Government Chest Clinlc, Pondicherry were obtained
from the case records and entered in a stnrctured form.
7 3 3 Cost analysrs
Data on the expenses assoc~ated w~th the annual household consumption d~rect cost
of Illness of a ch~ld to the fam~ly d~rect cost of school educatron of a ch~ld and the
expenses assoc~ated w~th some Important soc~al events In the famlly lhke celebrat~ng
attainment of puberty marriage and flrst chlld b~rth to a g~rl were obta~ned to f~nd out
the economlc burden of hawng a g~fi ch~ld In the fam~ly Data were collected on a
predeslgned and pretested structured form from the famil~es from which the cohort of
chlldren were selected For d~rect cost of ~llness, deta~ls of expenses assoc~ated with
glvlng health care dunng the one year followup penod were obtalned For expenses
assoc~ated w~th celebrat~ng attainment of puberty mamage and first chlld blrth to a glrl,
data were obta~ned from those famrl~es that had such celebrattons In the preced~ng five
years
7.4 Results
Tne results pertaining to the issues under the social status of school age ch~ldren,
denved both by ethnographic and other epidemiological methods are descnbed in thls

sectlon For each Issue, the observations by ethnographic methods are presented
followed by results denved by other ep~demiological methods.
7.4.1 Gender preference in having chlldren
(a) Ethnoaraphlc methods
In group d~scuss~ons, both women and men seemed to prefer hanng sons
However
structured questlonnalre revealed that only 25 6% (411160) wanted to have sons wh~le
many (46 9%) preferred to have both a glrl and a boy About 15 0% d~d not mlnd a
ch~ld of elther sex whlle 12 5% preferred to have g~fis About 56 3% thought that boj;
were essential for economlc support and 52 5% wanted to have boys for canylng the
famlly name The vanous reasons obtalned on the St~~t~red quest~onnalre for
preferring a chlld of a part~cular gender are given In Tables 7.2A and 7.28 It was
observed that people dld not dlsllke girls The value of glrls was appreciated by many
people as regards look~ng after the parents when necessaly and helplng them In
housework
About 26 3% sald they would llke to have glds because they were
affect~onate helped them In housework and looked afler them In old age The maln
reason for not wantlng girls was the expense assouated w~th her mamage
Some
people (19 4%) considered that both g~rls and boys were equal these days and that
there was no difference between them because both went to work and earned The
lnvest~gator observed that In the study vlllage there were a couple of famll~es where
the w~fe had undergone tubectomy after havlng two daughters One of the key
lnfomlants mother remarked ' My ne~ghbour IS a sup&
lady. She has only two
daughters and has undergone family planning operat~on. She IS bnnglng them UP
Well and 1s qulte happy " 'Super means very good In wlloqulal tenlnology

The fo//owing were some of the statements made in this regard:-
1. "A boy will carry on the family name" (A 30 year old man in an in-depth
~nte~ew).Several people expressed a s~milar new.
2. "A son will do the funeral rites when we are dead" (A 40 year old woman in an
In-depth inte~ew)
3. "In old age we can go and stay w~th our son even if it is a small house" (A 36
year old man In a group d~scuss~on)
4. "It Is very expensive to have a girl. Wm hmvm to givm her dowry. Than
childbirth. If her husband is not all right she will come home crying and we
have to look after. Lifelong there will be one expense after another. If it is one
girl we can manage. More than that is very diicuit" (A 40 year old man In a
group discuss~on).
5. "These days only girls look after parents. I am now looking after my mother. I
am sure in my old age my daughter will look after me. If I fall sick, is my
daughter-in-law going to nurse me?" (A 32 year old woman In an In-depth
interview)
6. "What does it matter whether it is boy or girl. Nowadays both go out and earn"
(A 33 year old woman In an tn-depth inte~ew).
Case Study
Neelavathy was a 50 year old widow. Her family was one of the families ~ncluded in the
cohort. She had two sons and a daughter. All of them were mamed. She was an
agricultural laborer and so were her sons. Her sons were staylng separately as she
had fought with them. She was staying with her mother along wiVl her daughtets son
who was studying in Kedar. She had borrowed Rs.20,000 for her younger sons
wedding and both tlie sons refused to help her pay back the loan. Her eldest son had
3 daughters. The first daughter was 4 years old and the second, thtrd were tWlnS.
Neela\ rthy's daughter-in-law was very unhappy about havlng twin g~rls. So she

"eglected the smaller of the twlns
She just abandoned the chlld and took her other
children and went away to another vlllage Neelavathy felt sorry for the neglected girl
ch~ld She brought the baby home, fed her and took care of her The baby repeatedly
fell s~ck Neelavattly took her to the local PHC and bought medlclnes to the best of her
capac~ty She sald. "What can we do ~f 11 IS a girl It IS not In our hands I just could not
bear to see my own grand chlld be~ng neglected I am do~ng my best for her" Afler 3
months the baby Improved and the baby s mother came and took back her ch~ld Thls
case study shows that a g~rl chlld can be neglected under pressure by the mother The
qrand mothers att~tudr rrflrrted that !tie q~rl chlld was st111 a ch~ld for the (am~ly In the
study area
7 4 2 Nutrition and the girl child
[a) Ethnographic methods
The villagers dlci not seem to glve any spec~al preference to thelr sons. In glvlng food
Structured obselvatlon focused on thls Issue dunng vls~ts to the vlllage In the study
penod also conf~rmed th~s The food that was prepared was d~stnbuted according to
each ones need among the fam~ly members About 53 0%, (851160) sa~d that whoever
was hunqry ate flrst In the house and 43 0% sa~d that the~r ch~ldren ate flrst
However.1 9% sa~d that they gave food flrst to the male ch~ldren A few women In the
group dlscuss~on felt that boys were fussy about food and were dlfflcult to please whlle
glrls were more accommodat~ve The adolescents who partlupated In the group
~ISCUSSIO~S were unanimous In saylng that there was no d~etaiy dlscnmlnat~on In the~r
houses Anandh~ once sa~d, " We are three daughters and one son. Whenever my
father br~ngs home anything to eat, he dlv~des Into four equal parts and glves us."

The follow~ng were some of the statements made In this regard .-
I. "In my house, children eat first, then my husband; I eat last" (A 32 year old
woman tn an ~n-deplh interview) Stmilar statement was made by many women
2. "My son will not have 'koozh". I have to cook something special for him.
My daughter will not say anything.
She will feel sony for me and eat
whatever I cook" (A 35 year old woman In a group d~scuss~on)
3. "It depends on how you have trained them. I will not cook anything special
for my son. He has to eat what I cook. If he doesn't like he has to starve"
(A 36 year old woman ~n a group dtscuss~on)
jb) Other epidemioloaical methods
The cornpanson of the actual Intake of d~fferent nutnents wlth he RDA, by age and
gender has already beer1 presented in the chapter on health aspects (Chapter 5 4,
Tables 5.10A-5.11E) There was no d~etary dlscnmlnatton between the genders as per
the data
7.4.3 Health care and the girl child
la) Ethnographic methods
People generally felt that attentton should be glven to a slck chlld, whether a glrl or a
boy They d~d not glve d~fferential care for girls and boys The type of treatment they
gave depended upon the money they had w~th them at that t~me Dunng a group
dlscuss~on, the pnmary school teacher sa~d."ln this village, they do not differentiate
between a sick girl and a sick boy. I have noticed that they have a lot of affection
for girls. Whenever a child falls sick, whether it is a girl or a boy, they take them to
a doctor immediately." Of the respondents to the structured questlonnalre, some
(531160, 33 I%.) said that they would go to a pr~vate doctor for mlnor allmenis and

many (53 1%) preferred to take them to a government hospital because ~t was less
costly However. for serious ailments, 98.1% said they would go to a private doctor
because the care and attention were better and cure was faster.
The follow!nQ were some of the statements made in thrs regard :-
I. "Whether it is the first child or last child, or a girl or a boy, if any child falls
sick, the same attention will be given" (A 39 year old man in a group discussion).
Thls mew was expressed by many people, both women and men.
2. How will a mother neglect her child? - All children are ours and we have the
same affection for all of them. Even if we have 5 daughters we will give them
the same care" (A 36 year old woman in a group discussion)
3. "If we have money we take to the doctor at once. If we don't have money we
go to a government hospital" (A 33 year old woman in an in-depth inte~ew).
4. "Who will go to a government hospital?. They are very rude and impolite. If
we had money, we will go to private doctor even for minor illness" (A 34 year
old woman in a group dlscuss~on).
jbl Other ep~dem~oloa~cal methods
To study thls Issue of health care data were also collected from the study vlllage dunng
cerisus lertlary care tiosp~tal and the Government Chest Cl~nlc. Pond~cherry The
results of the data collected from these three sources are descnbed below -
(i) Data from rural area
3 Immunization
Data collected at the time of Census
Out of 503 girls between 5-20 years of age, 426 (84 7%) and 465 (90.1%) out of 516
boys in the same age group were completely immunized The difference was
statlstl~ally s~gn~f~cant (p < 0.05).

Cross sectional morbidity survey in school
in the school morb~d~ty survey, 217 out of 591 girls (36 7%) and 274 out of 758 boys
(36 2%) had evldence of ~mrnun~zat~on w~th BCG vacwne The d~fference between the
genders was not statlstlcally slynlflcant (p > 0 05)
Cross sectional morbidity survey and cohort study
There was no slgnlflcant d~fference In the overall rnorb~d~ty between girls and boys as
per school survey and cohort study The average dlsorder per ch~ld ~n the school survey
was 2 5 for both girls and boys In the cohort study, the average eplsode of illness per
glrl was 1 4lyear and per boy 1 5lyear
:> Attention in sickness and type of health care
Cross sectional morbidity survey and cohort study
It has been ment~oned under the results In the chapter on health (Chapter 5 4), that no
s~gn~f~cant d~fference was observed In the type of health care glven to girls and boys as
revealed both In the cross sect~onal morb~d~ty survey and In the cohort study Further ~n
the cohort study, ~t was observed that 7 out of a total of 127 ep~sodes (5 5%) of
Illnesses In girls and 13 out of 179 (7 3%) ep~sodes of lllnesses In boys were glven
rnedlcal attent~on after a delay of 2 days from the onset of illness The d~fference was
not statlsttcally slgnlflcant (p > 0 05) In the remalnlng chrldren, attention was glven
Wlthln 24 hours

(11) Data from tertiary care hospital
, Hospital attendance
During a orie year per~od frorn June,lSSG to May, 1997, data were obta~ned at weekly
Intervals from ch~ldren between the ages of 515 years who attended JIPMER hosp~tal
There was a total of 1.443 chlldren In that age group, out of wh~ch 693 (48 0%) were
glrls and 750 (52 0%) were boys show~ng that there was no slgnlflcant gender
difference In the hospltal attendance rate In this area (p > 0 05, Table 5.28)
Attent~on in acute illness and type of health care
Details of treatment glven from the tlme of onset of the flrst symptom till the t~me the
ch~ld got adm~tted In the ped~atnc ward were obta~ned for 41 g~rls and 39 boys over a
perlod of 3 months These ch~ldren had fever or severe paln or a life threatening
symptom l~ke conwisions as the first symptom of illness The t~me Interval between the
oliset of illness and f~rst health care glven and also the type of flrst health care glven to
glrls and boys have been compared in Tables 7.3 and 7.4 No slgntflcant dlfference
was observed between the two genders elther In the tlme Interval between the onset of
~llness and the flrst health care glven or the type of f~rst health care glven to them The
mean delay In seeklng med~cal help In g~rls was 2 4 el 5) days and in boys 2 6 @2 1)
days there be~ng no stgn~ficant dlfference between the two (p >O 05)
3 Attention in chronic illness (cerebral palsy)
From the case records of chlldren wlth cerebral palsy who had attended the
Occupat~onal therapy department of the hosp~tal durlng a one year penod between
Januafy,1994 and December.1994, 78 were selected for analysls Thls Included case

ecords of 34 girls and 44 boys
The case records were so selected that the
background seventy and durat~on of ~llness, and souoeconomlc
status were
comparable In both the groups Out of 34 g~rls. 9 (26 5%) d ~d not come for any follow
up at all while the correspond~ng f~gure for boys was 16 out of 41 (36 4%) It was also
observed that 15 out of 34 glds (44 1%) and 9 out of 44 boys (20 5%) had completed
thelr full course of followup In those who dld not come for followup, no slgnlf~cant
d~fference was observed between the 2 groups (p > 0 05) In those who completed the
full followup, there were s~gn~f~cantly more g~rls than boys (p < 0 05)
(111) Data from Government Chest Clln~c, Pondicherry
Treatment of tuberculos~s
Dunng a 1 year penod between January 1994 and December,l994. 145 g~rls and 155
boys less than 15 years of age recelved treatment for tuberculos~s at the Chest Cl~n~c.
Pondcherry
Out of 145 g~rls 107 (73 8%) and out of 155 boys 106 (684%) had
completed full treatment, no s~gn~flcant d~fference belng observed between the two
genders (p > 0 05)
7 4 4 Education and the g~rl ctlild
(a1 Ethnoqraph~c methods
The villagers were unanimous In the~r oplnlon that educat~on was equally necessary for
glds as much as for boys
Out of the 160 people who responded to the St~ctured
questlonnalre, 96 3% felt that g~rls should take up jobs wh~le only 3 8% thought that
lobs wore not essent~al for them Although most people (71 9%) were wtll~ng to send
the11 daughters outs~de the v~llage for study or work, a few (5 6%) were unwllllng to do

so However, some (22 5O/0) were w~ll~ng to send them w~th an escort Selvl once sa~d,
dc
lt is so much better now. So many girls go to school and take up jobs outside
the village also. About 5 years ago, very few girls went to school outside the
village. My father had to face a lot of criticism from his relatives and neighbors for
sending my slster to Dind~gul for nurslng training." Most people (80 0%) were w~lllng
10 borrow money for the~r son's educat~on On the other hand, not many were w~lllng to
do so for the~r daughter's educat~on Only about 65 0% sa~d that they would borrow
money for thew daughter's educat~on, and, that too, only ~f she d~d well In school Slnce
they had to spend on her rnarrlage any how, they were not keen to spend on her
educatlon Many (60 6%) felt that educat~on would not make a girl's mamage easler or
less costly Only 39 4% felt that ~t was easler for a g~rl w~th a job to get marr~ed Most
of them (99 4%) thought that menarche these days would not Interfere w~th a glrl's
educatlon
The follow~ng are some of the statements made m th~s regard
1. "I think it will be good if girls read and take up jobs. Then even if her husband
leaves her, she can earn and look after her family" (A 33 year old woman In an
In-depth ~nte~ew) A s~m~lar statement was made by many people
2. "1 wish I had educated my daughters. At that time I was thinking how I was
going to get them married and did not think about sending them to school.
Now I see so many girls reading and getting jobs and having status in society.
I wish I had also educated them" (A 45 year old woman In an In-depth lntervlew)
3 "My daughter has studied upto the Vlll standard only. I wanted her to become
a nurse. She was not reading well. We could have sent her for tuition. But
her father said we can't afford to educate all our children. It is more important
to educate boys. Anyway she is not reading well. Let her stay at home and
learn housework. So, we got her married" (A 40 year old woman ln an In-depth
Inttrv~ew)

4 "Girls cannot just go anywhere for studying. If it is a boy and if it gets late, he
will stay in his fnend's house. A girl cannot do that. She can read if the school
IS in the village ~tselP' (A 40 year old man In a group dlscuss~on)
"If the girl IS educated the11 we have to look out for an educated boy" (A 40
year old woman tn a group d~scuss~on)
6 "ARer XI1 standard, I jolned the correspondence courcie at Annamalai
Unlverslty. My parents were not keen ~nitially. Later they agreed and did not
put any obstruction" (A 22 year old woman ~n an In-depth ~ntervlew)
p) Other Ep~dem~oloq~cal Methods
Data were obtalned on thls Issue of education and the girl chfld from the vlllage while
taklng census, as well as from the cohort Though the results have been mentioned In
the chapter on educat~on (Chapter 6 4), relevant findlngs wlth respect to the girl ch~ld
are summansed below
(I) Census
-. Signlftcantly more number of boys than girls (between 520 years of age) were
enrolled ~n school In the study vlliage as shown by the fact that 430 out of 503
(85 5%) g~rls and 482 out of 516 boys (93 4%) were found to be enrolled ~n school
at the tlme of taklng census (p < 0 05)
., The proport~on of ch~ldren studylng In the prlmary and m~ddle school was
sign~flcantly more In boys when compared to girls (p < 0 05)
No s~gn~f~cant
difference was observed between the genders ~n the proport~on who were studylng
In h~gh school (p > 0 05)
Among the village populat~on over 20 years of age, a sign~flcantly h~gher proportlon
of males had completed h~gh school educat~on and college educat~on (21 0% and
5 0%) respectively when compared to females In whom the correspond~ng flgures
were 6 9% and 1 3% respecbvely (p < 0 05)

(i~) Cohort
3 In the cohort, 54 out of 96 girls (56 3%) and 89 out of 119 (74 8%) boys were
study~ng, the proportion of boys studylng belng s~gn~ftcantly more than girls (p <
0 05)
-, Among those who were studylng 31 g~rls (574%) and 35 boys (39 3%) were
atlend~ng extra r

labor wh~le the~r slsters relaxed at home Most of the le~sure time was spent by boys ln
going out or for clnemas, whlle g~rl stayed at home or went to the local temples
The follow~ng are some of the statements made in th~s regard -
1. "A glrl only has to do all the inside work. Then only she will be able to do
these jobs well, when she goes to another house" (A 35 year old man In an ~n-
depth Internew) Many people expressed a slmllar new
2 "A boy should not do housework. I will not allow it. If he starts doing that, he
will become lazy and will not go out and earn. His main duty is to go out and
earn" (A 32 year old woman In an In-depth ~nte~ew)
3. "Boys have to do all the outside work like getting things from the shop or
outs~de the town. they will not do inside work. I will not permit them" (A 35
years old woman tn an In-depth ~nterv~ew)
4. '1 do all the work like going to the field, washing vessels, cooki~g and making
pavu. My brother goes for field work and weaves. He doesn't do any
housework. When I am not tired, I don't mind doing housework. Sometimes
when I am tired I feel bad I have to do all the work. When I have children I will
ask them to share the housework" (A 20 year old glrl ln an In-depth lntervlew)
5. "What work do girls do? They just sit at home and gossip. We only have to go
out and work in the hot sun" (A 19 year old boy In a group dlscusslon)
-her
epidemiolo~ical methods
The duration and changlng pattern w~th lncreaslng age of important dally actlvltles llke
work, study, leisure and play, and sleep are glven below These actlwt~es In g~rls and
boys In the vanous age groups are compared ~n Tables 7.5-7.7 The durat~on of the
danous actlv~t~es, expressed as a percentage of the total tlme penod ~n a day, for both
girls and boys IS glven ~n Figures 7.lA-7.2 C

(i) Work
The daily actlvlty pattern between gtrls and boys In the age group 5-15 years was
compared only In those who were studylng In school Slnw there were only 3 boys who
were not In school In that age group, ~t was not poss~ble to compare In chlldren who
were not studylng In the older age group (16-20 years), the companson was made only
among those who were not studying Since there was only one girl In that age group
who was studylng. ~t was not poss~ble to compare In chlldren who were study~ng For
g~rls, the mean work load Increased from about 0 9 hourslday between 5-10 years of
age, to about 6 hounlday beyond 10 years of age However, in those who were golng
to school (between 11-15 years). ~t was about 2 3 hourslday In boys, ~t Increased from
about 0 5 hourslday In the 5-10 year age group, to about 4 1 hourslday In the 16-20
year age group whlch was the maxlmum Although the mean work load was h~gher In
girls In all the age groups, ~t was found to be statlstlcally s~gnlficant only among those
who were studylng, In the age group 11-15 years (p c 0 05) However, there was a
d~fference In the work pattern as shown In Figures 7.3 A-7.4 C For g~rls, housework
compnsed more than 44 0 Oh of thelr work load In all age groups, the maxlmum (65 4%)
being recorded between 5-10 years The proportion of thelr total work load In Income
generatlng work, Increased from about 2 0 % In the younger age group to about 40 0 %
ln the older age group The outs~de work burden (as % of thelr total work load)
decreased from 32 6% lo 12 1% w~th lncreaslng age
For boys, ~t was observed, that the Important component of the11 work load (64 3%)
was dolng outs~de work ~n the younger age group (5-9 years) and In Income generatlng
work (78 0%) In the older age group (16-20 years) Boys were also observed to do

housework Between 5-15 years, about 7 0%-12 0% of thelr total work burden was
spent In housework This propofi~on reduced to 2 0% In the age group 1620 years
(11) Study
In the age group 5-10 years no slgn~flcant dlfference was observed between girls and
boys In the average tlme spent In stud~es (0 7hourslday vs 1 hourlday respectively for
g~rls and boys, p > 0 05) On the other hand, between 11-15 years, although g~ris dld
more work than boys (2 3hourslday for g~rls, vs 1 3 hourslday for boys), they also
spent on an average 2 3 hourslday on stud~es as compared to 1 3 hourslday by boys
whlch was s~gn~ftcantly h~gher (p < 0 05)
(111) Leisure
The average tlme for le~sure and play ranged from 3 3 hourslday to 6 2 hourslday for
g~rls and 4 0 hourslday to 6 2 hourslday for boys The maxlmum lelsure was between
5 10 years of age No stgnlflcant dlfference was observed between the genders In the
t~me ava~lable for lelsure except In the school golng chtldren In the age group 11-15
years where boys had s~gn~ftcantly more lelsure (p < 0 05)
(IV) Skep
It was observed that In the study group, both gtrls and boys had adequate sleep
ranglng from about 8-10 hourslday (p > 0 05)
7.4.6 Influence of menarche on the status of the girl child
la) Ethnoqraohic methods
Out of the 160 respondents to the structured questlonnalre, almost all of them (99 4%)
felt that a glri could cont~nue w~th her schooling after menarche Though menarche dld

not interfere with a girl's education, most (88.1%) expected her to be restricted in her
activities and controlled in her behavior after attaining puberty. About 72.5% felt that
restnct~on was needed because others would pass adverse remarks. Some (18.1%) felt
that her mamage might also be affected. Yet, others felt that the girls on their own w~ll
control their behavior.
The following are some of the statements mede in this regard:.
1. "If she is reading or working she can continua to do that. At other tlmes, she
has to stay in the house. May be she can go to the temple with proper escort"
(A 30 year old man In an in-depth ~ntewiew). Many people expressed a similar Mew.
2. "1 don't think menarche changes a girl's lifestyle. Before menarche they do
some housework, watch N (television), wash vessels and help in cooking.
After menarche also they are going to do the same. Why should their life
change? (A 32 year old woman in an In-depth interview).
3. "Before rnenarche my daughter used to play around. ARer menarche she
remained in the house and was controlled in her behavior. She did it on her
own.
interview)
We did not tell her anything" (A 35 year old woman in an ~n-depth
4. "After menarche she should remain In the house. I wlll not allow her to talk to
strangers or outsiders. She can talk to guests at home. She can go to school.
If she attains menarche at 12 years itself I will allow her to play when others
are playing. I won't feel like telling her don't play. I will ask her to stop playing
when she is 15 years old" (A 35 year old man in an in-depth Interview).
5. "If she is not restricted in her behavior, mistakes will happen. The family's
name will be spoilt. If a bay makes mistakes, nobody will know" (A 40 year old
woman in a group discussion)
6. "Others wlll say, look at her behavior. She Is not trained properly. I wlll ask
her to remain in the house. Others should not comment on her behavior. At
tho tlltlo of lnnrriago pooplo will toll tho prospoctlvo groolti that lllo girl la
irresponsible. She just watches TV (television) and wanders around. The boy
will think she will not do any housework and go away" (A 32 year old woman in
at2 In-depth ~ntewiew).

jb) Other ep~dem~olo~~cal methods
In the cross secttonal school rnorbld~ty survey. 11 was observed that the average age of
rnenarche was 14 3 ( ~ 3) 1 years Out of 248 girls 13 yean of age and above, 105 glds
(42 3%) had attalned rnenarche and were continuing In school
7.4 7 Marriage
(I) Ethnographic methods
Many people (12 11160, 75 6%) felt that g~rls should get mamed after the age of 20
years only About 63 8% thought that only then will she be responsible and strong
enough to bear ch~ldren However, some (24 4%) felt that they should get mamed
before 18 years because others would say something They felt that ~t was not nlce to
have an unmamed gld In the house The most Important requtslte for a glrl's mamage
was money Thls was clear from the observat~on that 85 6% felt that money was the
most essent~al requlslte In gettlng a g~d mamed Only 5 6% felt that education was
essent~al Some (23 4%) also felt that girls should be healthy and be capable of
worklng Most people (756%) thought that lack of money was the most common
reason for delay In a glrl's mamage However, a delayed mamage dld not affect the
status of the famlly In soclety Many people (65 0%) would lust thlnk that her tlme was
not good while some (24 4%) would not thlnk anythlng at all

The following are some of the statements made in this regard:-
I. "If a girl gets married at a younger age, she will be playful and will not look
after her family" (A 36 year old woman in an in-depth interview).
2. "The sooner a girl gets married, the better. Having an unmarried girl in the
house is a big burden. It is like having fire in the stomach. We have to reduce
our burden. (A 39 year old woman in a group discussion).
3. "Not having money is the main reason for the marriage of girls getting delayed.
Money is everything. Even if the girl is not good looking, if they give more
sovereigns, the girl will get married" (A 35 year old woman in an in-depth
intew~ew) Many peopie expressed a similar view.
4. If the girl is nice to look at, she will get married quickly. If she is not, people
will say, she is dark, her teeth are prominent and things like that. If she has
some problem like abdominal pain she will not get married. If the boys people
come to know of it they will not marry her because she will not work.'' (A 30
year old man ~n an in-depth inte~ew)
5. "If there is an unmarried girl in the house, people will say whatever they feel
like. Neighbon will talk more than relatives. We may feel hurt by their remarks
sometimes. But why should we not take part in other functions? It will look
bad if we don't attend" (A 45 year old man in a group discussion).
(ii) Other epidemiological methods
Dur~ng census it was observed that out of a total of 136 girls between 15-18 years of
age ~n the village, only 14 (10.3%) were married.
(i) Ethnographic methods
All the 160 respondents to the quest~onnalre felt that a boy should get marned only
after 25 years of age when he becomes responsible enough to look after a famlly

There would be no problem In gettlng a boy mamed ~f he had a job About 55 6%
cons~dered hawng a job was very essent~al for a boy to get mamed, whlle some
(32 5%) felt that In add~tion, good character and conduct were also essent~al Only
3 8% thought that money was very essent~al for a boy's mamage Some (20 6%) felt
that even ~f a boy had a job, hls rnamage m~ght get delayed, ~f he had a slster of
marnageable age It IS the custom In the local area to get the daughter mamed flrst ~f
both daughter and son are In the marr~ageable age In the same famlly
The following are some of the statemenb made in this regard -
I. "If the boy has a job, there will be no delay at all in getting him married" (A 35
year old man in a group dtscuss~on)
2. "A boy can get married if he is capable of earning well. If he remains idle and
does not earn who will many him?" ( A 32 year old woman In an In depth
~nte~ew)
3. "If a boy does not have a job he h~mself might not want to get married till he
got a job" (A 35 year old man In an In depth ~nte~ew)
4. "If a boy is unhealthy or he does not have a job he will not get married.
Sometimes he may have younger sisters who are to be married (A 35 year old
woman In an In-depth ~nte~lew)
5. "Why should the boys marriage get delayed? He gets whatever he wants from
the girls house" (A 40 year old man In a group dlscusslon)
111) Other epidemiological methods
In the study v~llage, there was not a single boy below 21 years of age who was marr~ed
7.4.8 Cost analysis
Out of 100 famll~es randomly selected for the cohort study, one famlly rnlgrated Out of
the village Therefore data on Issues perta~nlng to the economlc aspects of the Study

was collected from 99 familles The average annual income per family was Rs.12.453
(Y53 0)l- and per head Rs 2,201(*36.0)1-
(a) Household consumption cost
This 1s shown in Table 7.8. It was observed that the average total expend~ture per
annum per famlly exceeded their average annual income.
jb) Direct cost of illness
Out of 93 glrls and 116 boys followed up for morbidity, illness was observed In 70 girls
and 96 boys. The detalls of the direct cost of illness are given in Table 7.9.
(c) Cost of educatlon
Data were obtalned from the school on the cost of educatlon of a chlldlyear In the
pnmary mlddle and hlgh school levels (Table 7.10) In the cohort group there were 58
54 and 31 chlldren respectlvely studylng In pnmary mlddle and hlgh school They were
from 80 out of the 99 selected famil~es The total expenses for the pnmary school
ch~ldrenlannum was Rs 8701- The expenses In the middle and h~gh school per annum
were Rs 271351- and Rs 233741- respectlvely
The average cost of educat~on per
famlly per annum was Rs 6421- ar~d per chlld Rs 3591- (Table 7.11).
The average recurrent expenses to a rural fam~ly are shown In Table 7 12 A
@) Cost of celebratinn social functions
(1) Menarche
Out of the 99 famllles, there were 39 farnllles that had celebrated puberty (for 40 glds
since 1 famlly had celebrated for 2 gtrls) dunng the prevlous 5 years
The total

expendlture Incurred was Rs 1,23.900 with an average cost per family of
Rs 3,177(+48 O)1- and per girl Rs.3038 (k45.0)/- (Table 7.12 8).
(11) Marnage (girl)
Durlng the preced~ng 5 years mamage celebration were performed by 17 famlltes for
thelr daughters There were 2 famllles that had perfoned 2 mamages The total
number of girls whose rnamage was celebrated was therefore 19
The total
expendtture was Rs 5 30 000 wlth an average expenselfam~ly of Rs 31 176
(tl 021 0)i- and per g~rl Rs 27 895 (i985 0)i- (Table 7 12 B)
(iii) Marriage (boy)
Data were collected from 10 farn~lies that had celebrated the marriage of their sons (10
sons) The total expenditure incurred was Rs.2,31,000 with an average expenselfam~ly
of Rs 23,100 (t777 0)i- (Table 7.128)
(iv) Child birth
The total expenditure incurred by the 11 families in connection with the birth of the first
child of thelr daughter was Rs.64,000. This glves an average of Rs.5,818 (3222.0)lchild
b~rthifamily (Table 7.128).
7.5 Discussion
The social status of children in a commun~ty reflects the cornmunlty's perceptlon and
attttude towards them. Although extensive research has been done on the Issues
relating to the social status of adolescents and young women In India and other
couril es (Okojie,1994; Vlassof,l994), there are only a few studies which have focused

on the Issue of school age g~rls (UNICEF,1990) Ch~ldren s poslt~on In soclety IS largely
dependent on thelr status In the home context The importance glven to the~r nutntlon
health educat~on and other actlvltles w~thln thew homes 15 a measure of thelr status
Therefore In the current stud!
these Issues were addressed marly to assess the
status of school age chlldren In the~r home m~l~eu w~th emphasls on bnnglng out the
difference between girls and boys These Issues have also been addressed uslng both
qual~tatlve and quantltatlve ethnograph~c methods, whlch have not been used In earl~er
stud~es from lnd~a to the best of the ~nvest~gatots knowledge The Issues cons~dered
were as follows -
7 5. I Gender preference in having children
lnd~a IS known to be one of the countr~es w~th a h~gh Index for son preference
(Oduntan 1995) Thls IS posslbly because of the fact that people In states I~ke. Punjab
Rajasthan, Uttar Pradesh and Madhya Pradesh are known to have a strong preference
for boys In these states, the under flve mortal~ty of the female chlld 15 much htgher than
the males (UNICEF.1990) Further, the lower sex ratlo In these states compared to the
natlonal average of 927, also lndlrectly reflected the better care glven to males
However, there IS a heterogene~ty of gender preference In lnd~a as shown by a h~gher
sex ratio ~n the Southern states of Tam11 Nadu, Kerala, Andhra Pradesh. Karnataka and
the Eastern state of Orlssa, where ~t IS
more than 950 (Potdar.1992) Some
lnvest~gators were of the oplnlon that the gender b~as was greater In areas where the
economlc potent~al of females was low
Rec~proc~ty and br~de wealth whlch were
common In the South, enhanced the value of women In these areas (Bardhan,1988)

In Tamil Nadu, the gender preference was not very strong. This was shown by the fact
that In a survey, it was found that only 29.0% of married women desiring another child
wanted sons wh~le 17.0% wanted to have girls (Anonymous,l9%ia)
However, there
are a few pockets near Salem where female infanticide has been reported (Kulkam~ et
a1,1996) In the study area, which is part of Tamil Nadu, the sex ratio being 1,004
does not reflect a strong preference for sons. While a majority of the respondents to
the st~ct~red questionnaire (46.9%) preferred to have both a glrl and a boy, only
25 6% of the respondents wanted to have sons. The main reasons for prefemng sons
by the respondents were'(i) to carry the family name. (ii) to give economic support (iii)
to perform funeral rites, (iv) ~t was a great financial burden to have girls, (v) girls get
rnarr~ed and leave the family Similar reasons have been cited for preference of sons.
elsewhere in the world (Okojie,1994). Among the respondents 12.5% wanted to have
daughters because they were affect~onate, helped with domestic work and looked after
them In old age. In local terminology, a girl was referred to as "paapa" which means a
small child and the boy was known as "Thambi" which means brother The cultural
concept in this part of the country 1s that a girl will always be a small child to be
cher~shed and protected by the brother
7.5.2 Nutrition and the girl child
The d~etary adequacy and dietary discrimination at home reflects the soc~al status of a
chlld. There are several studies from India that found differences in the dietary Intake
between girls and boys. It was observed that girls usually received what was left over
and the dietary inadequacy was more when compared to boys (Ghosh,l992).
Dlscrlmlnatlon in feeding practice lnvolvlng both quant~ty and qual~ty of food has been
reported from Punjab, Uttar Pradesh and Bombay (Ghosh,1992; Thomas,1992). It has

een found that in some parts of the country, girls were breast fed for a shorter period
(Ghosh.1986). Energy, protein, vitamin A and iron intake was also less ~n girls than
boys (UNICEF,1990). The nutritional inadequacy usually resulted in a hlgher
percentage of malnutrition and other nutritional disorders in girls as compared to boys
(Ghosh,1992; Thomas.1992; Khad~ et a1.,1996). However, the nutritional bias was not
uniform auoss the country. It is greater in the North than in South India (Ghosh,l986,
Subrahmanyam and Rao.1995)
This is also supported by the fact that most of the
stud~es reporting dietary dlsuimlnation have been from the North (Ghosh,l992,
Thornas,1992). Studies from Hyderabad (Andhra Pradesh) and Salem (Tam11 Nadu)
have shown that the dietary intake of girls and boys were simllar (Brahman el a1.,1988,
Samantaray and Jena,1995). Other investigators have observed equal or even better
energy intake in girls as compared to boys (Rao, 1989). In the current study, school
age children consumed inadequate nutrients. This nutribonal Inadequacy was uniformly
observed ~n both the genders by d~etary survey and nonparticipant observat~on. There
was no s~gn~ficant difference in the proportion of girls (54.5%) and boys (60.2%) who
were malnourished. Thus both dietary survey as well as nutritional status of children dld
not polnt to any dietary discrimination against girls in this study. This reflects a relatively
hlgher social status of the girl child in this part of the country, when compared to other
localities.
7.5.3 Health care and the girl child
Health care glven to a child could be both preventive and curatlve
The preventive
health care includes immunization against common infectious diseases. In different
states In lnd~a, the immunization coverage is not uniform in glrls and boys. Stud~es In
Blhar and tribal areas of Maharashtra showed a slightly higher immunization coverage

In boys than in girls (Daga.1992; Srivastava and Nayak,1995). On the other hand, there
are studies that have not shown any significant gender difference In immunization
coverage (Ghildiyal et a1..1992. Samantaray and Jena.1995). In the current study, the
data collected during census showed a significantly lower proportion of girls (84.7%)
than boys (90.1%) completely immunized with DPT and OPV(p < 0.05). However, cross
secbonal morbidity survey did not reveal any significant difference between the genders
with respect to BCG vacdnat~on (p > 0.05). These data suggest a marginal preference
of boys over girls as far as immunization coverage was concerned.
AS In the case of preventive aspects, the curative aspects also show a heterogene~ty of
gender bias in India. In India the male: female hospitalization ratio varied from 2.1 to
1 3 1, the latter being mainly from the South (Ghosh,1986). A study from Bombay
showed that the ratio of male: female hospltal attendance was 1.4:l (Ghildiyal et
ai.1992). In a hospital from Ludhiana, it was observed that 65.2% of the attendance
was boys and 34.8% was girls in the pediatric outpatient department (UNICEF,1994b).
In the same place, it was also found that boys received earlier medical attention than
g~rls dunng their terminal illness (Kielman,l991). In a study from Salem, it was reported
lhat boys were taken to doctors, whereas girls were given home medication
(Samantaray and Jena,1995). These data suggest greater utllizatlon of health service3
for slck sons than sick daughters in some parts of the country resulting in a higher
mortality and morbidity in girls
(Ghosh,1992; Ghildiyal et a1.,1992; Oko~1e,1994).
However, Basu (1989) observed that in Tamil Nadu, the chances of survival In early
ch~ldhood, were almost equal for girls and boys. This implied that the health care for
gldS was not different from that of boys, in Tamil Nadu. In the current study, no
S19nlflcant gender difference was observed in JIPMER hospital atlendance, be~ng

48 0% In glrls and 52 0% In boys The study also showed no s~gn~f~cant d~fference
between glrls and boys e~ther in the overall rnorb~d~ty
the health care glven by
parents to acutely 111 and chron~cally s~ck chtldren The promptness wlth wixch illness
was attended to and the type of treatment glven were essentially the same In both girls
and boys For acute tllness, the average delay In seeklng med~cal help was 2 4 days In
gtrls and 2 6 days In boys These f~ndtngs suggest that In the study area, girls rece~ved
the same attentten as boys wtth respect to curattve health care Considering both the
preventive and curatlve aspects of health care the girl ch~ld can be sa~d to have almost
equal status as the boy In this part of the country
7.5.4 Education and the girl child
In Ind~a, the enrollment rate for glrls has always remained less than that of the boys
(UNICEF.1990) Even in states like Tamil Nadu and Maharashtra which have a high
literacy rate, the enrollment rate in girls was lower than boys (Nagpure,l992,
Anonymous.1996). Qualitative research in th~s study showed that most of the villagers
felt that education was important for girls. However, they were willing to educate them
only as long as education was affordable and accessible. While many were willing to
spend extra money on their son's education, only some were willing to do so for girls It
was found that among children between 520 years of age, less number of glds
(05 5"/0) that1 boys (93 4Yo) wore enrolled in sctrool (p < 0 05)
It has been observed in many states in India, that g~rls had a lower attendance rate
than boys in the primary and middle school levels. Some states l~ke Uttar Pradesh,
B~har and Rajasthan showed a very wide d~fference between the genders. The
dlf' :rence was lowest in Kerala (UNICEF,1990) In the current study also lt was

observed that the propohon of girls attending pnmary and m~ddle school was
s~gnlflcantly less than the proport~on of boys attending the same (pnmary school 75 1%
for girls, 00 5"X) lor boys, mrddle school 71 3'h for glrls, 81 7% for boys) Ilownvnr, nt
the high school level, the attendance rate In girls and boys were comparable (54 4% vs
52 4% respectively) The fall In attendance rate from m~ddle school to h~gh school was
greater In boys than In girls Thls 1s l~kely to be due to lack of senousness w~th respect
to stud~es on the part of boys, or, the need for them to contnbute to the Income of the
famlly Whereas In the case of glrls, it 1s poss~ble that those who complete rn~ddle
school are motrvated to continue wrth the~r educabon (~f they can afford), as they are
senous about taklng up jobs The opportun~t~es for jobs for girls are better than before
In many parts of lnd~ and the developing world, the dropout rate has been reported to
be higher In glrls than in boys (UNICEF,1994a) In Rapsthan, the drop out rate In g~rls
was as hlgh as 57 0% (UNICEF,1990) In Maharashtra, it has been reported, that the
number of dropouts In g~rls was h~gher than boys at all levels of schooling
(Nagpure,l992) In Tam11 Nadu, the dropout rate In girls (17 0%) was marginally h~gher
than boys (14 9%, Anonymous,l996) In the study wllage, although the dropout rate In
glrls (20 9%) was h~gher than boys (16 6%), the d~fference was not statlstlcally
s~gn~f~cant (p > 0 05) The causes of dropout were however d~fferent for girls and boys
Poverty was the most common cause for dropout In girls, whlle lack of Interest and poor
performance were the chlef causes of dropout In boys
Qual~tatlve research showed that most often boys stopped going to school on thelr
own due to lack of motlvatlon and the deslre to earn, whrle girls were stopped because
the parents could not afford or they were requlred for domestlc help
Menarche was
not an Important cause of dropout Occasionally, parents who could not afford, used ~t

as an excuse to stop thelr girls from gotng to school In Indla, some of the reasons
quoted for stopplng a glrl's education were -i) daughters get mamed and go away, 11)
they were more useful In household work, 111) ~t was unacceptable to send daughters to
a dlstanl place or to read under a male teacher, IV) ~t was easler to marry a less
educated glrl (UNICEF,l990) Further, the qual~tabve research showed that mamage
for educated girls becomes d~ff~wlt In terms of the cost as well as f~nd~ng a groom It
also revealed that an unmamed g~rl was a soual burden The parents therefore wanted
to reduce the burden by gettlng her marned as early as posslble In the late adolescent
age the pnonty for a girl In her soclal context 1s mamage and not educatlon
Education was not golng to make a glrl's marnage easy or less costly On the other
hand, formal schooilng as a prospective avenue for employment was more Important
for a son In lnd~a Th~s IS an Important motlvatlng factor for most of the parents wantlng
to give thelr sons the best poss~ble educat~on In some states l~ke Maharashtra and
Tam11 Nadu, there are lncentlves for promoting female educatlon In Maharashtra, girls
are glven free educat~on up to XI1 standard (Nagpure,1992) In Tam11 Nadu, there 15 a
speclal marnage grant for g~rls educated up to standard Vlll (Anonymous,l996)
Although these rncent~ves have Improved the enrollment and attendance rates of glrls
over the years, the rates have st111 not become equal to boys Thls 15 because of the
cultural practices and pressures that st111 keep the educat~onal status of a girl chlld at a
lower level
7.5.5 Daily activitypattern
Studles have shown that In children behveen 514 years of age, the mean work load In
Qlrrv was greater than that In boys In rural areas, whereas, In urban localltles, boys had

a greater work load (UNICEF.1990. Table 7.13) The reduced work load In girls In the
urban area 1s due to a redud~on In the partlclpatlon In non domestlc adlvltles In the
current study, In tbe younger age group, the work load In chlldren was less than that
reported from a rural area In the earher study (UNICEF,1990) The difference wuld be
because, In the current study. In the younger age group, all the ch~ldren except one g~rl
were studylng In school and those In the other study were perhaps not In school The
relatively lower work load obsewed In both girls and boys who were In school In the
current study, reflected the Importance glven to educabon In the study area
Both In the rural and urban areas, girls spent about 45 0% - 50 0% of thelr worklng tlme
~n domestlc actlvltles (UNICEF,1990) The current study also showed that for glrls,
housework contnbuted to about 45 0% - 60 0% of the total duratlon of work, For boys
the major share was taken by agricultural or allled work (Fig 7.3A-7.4C) This flndlng
corroborates that gathered by qualltatlve data, where people generally felt that girl:
should do housework and boys outslde work Thls percepbon poss~bly onglnates from
the deep rooted cultural practice of role play and d~wslon of labor Most people In the
study cornrnun~ty ~ncludlng the adolescents lnte~ewed seem to share th~s perception
The practlce of women staylng mostly In the house reduced the opportunity for
education, experience and eamlng capacity In the course of tlme they bewrne totally
dependent on men In Ideal sltuatlon, both outslde and household work should be
shared by both girls and boys
Allhough there are reports whlch polnt out that girls do not have t~me to relax or talk
and go out (UNICEF,1990), th~s study showed that they had plenty of lelsure In all age
S~QUC. It was also observed that, younger glds (510 years of age) spent less tlme In

stud~es compared to boys, although the total work load was not s~gn~flcantly d~fferent
between them Thls suggests a lack of senousness In young girls w~th respect to
stud~es Older girls (11-15 years of age) on the other hand, spent more time In stud~es
compared to boys of the same age group, desp~te hanng a s~gn~flcantly h~gher work
load than them Thls shows that girls as they grow, become more respons~ble and
Interested In pursulng education
7.5.6 Influence of menarche on the girl child
It IS known that In many parts of lnd~a girls at and after puberty suffer from a vanety of
restnct~ons and lnh~blt~ons wh~ch anse malnly out of concern for the safety of the girl
chlld Thls lowers the~r soc~al status by restnctlng thew movements and affecting thelr
educat~on In the study area girls were generally restncted after puberty, affect~ng thr~r
soc~al stalus However. ~t d~d not affect thelr educat~on much, slnce a large proport~on
of glrls In the nllage who had atta~ned menarche were found to wntlnue the~r
sctiool~ng
7.5.7 Marriage
The cost and customs related to mamage Influence the soc~al status of a g~rl ch~ld In
areas l~ke Kerala, where the females lnhent wealth, the soc~al status of the glrl chlld IS
not affected by the burden of mamage In most other parts of Ind~a, the soclal status of
a g~rl ch~ld IS lowered to a cons~derabl extent by the dowry system and the consequent
flnanclal burden on the famlly The quantum of the burden can be ~udged by the fact
lhat In the current study, the average expenses assouated wlth a girl's mamage Was
more t9an twlce the average annual Income of a famlly Th~s had to be shouldered by
the )arents alone Although the mamage expenses for a boy In the study nllage was

found to be qulte hlgh, the economlc straln was al$o shared by the boy, thus reduclng
the burden on the parents Moreover, the boys recelved dowry whlch part~ally
:ompensated the expenses As far as g~ris were concerned, In addlt~on to shouldenng
the economlc burden of gettlng them marned, the parents had to provlde her soc~al
secunty before marnage For these two Important reasons, parents would llke to reduce
the~r burden by gettlng her marned as early as poss~ble
The age of marnage IS l~nked to the soc~al status of the g~rl chlld In Ind~a, the mlnlrnum
age for marnage of a girl IS offic~ally 18 years However, a large proport~on of girls
(44 0%) get rnarrled between 15-19 years of age In lnd~a It 1s as h~gh as 60 0% ~n
some states l~ke Rajasthan. B~har. Madhya Pradesh and Uttar Pradesh (UNICEF.1990)
In Tamll Nadu, ~t 1s 27 2% (Anonymous.1994a) In the current study, ~t was observed
that only 10 3% of girls between 15-19 years of age were marned Thls clearly reflects
a better soc~al status for girls In thls locality than many other parts of lnd~a

TABLE 7.1 A
METHOD OF STUDY USED FOR DIFFERENT ISSUES ADDRESSED AND TIME FRAME OF DATA
COLLECTION
OBSERVATION
(MONTIIS)
1
PHhPkRhNl L Ih
H\\INl:
Qualilotive
I
FKUS group
Mld
Febnuy'%
dIscuss1ons
In-deplh 10 3.5 MId ~.y'%
lnlcrvlcns
Fsbnrar)'96
Case sludy ~nol~thly 6 Jd)'% Lkrrmbrr'%
Quantilafive
Slmclured one lime
kpllolbrr196 Novemkr'%
qucst~onnalrc
' hI I KITION AND E(hooeraphic
I
Qualitative
Focus group 2 hlq'96
dlscusslons
Indepth IU 3.5 Mid htq'%
~nlerv~eus
Rbnur)'%
Ke! 111lors1an1 as and when 22 AU6&"'9s >1.)'97
Iniervlcn
. Nonpart~clpm as and when 22 A"P"95 h1.y'97
t obsenal~on
C)uonlilali~~e
Structured one llme
Cpllrn&r'%
Nn>rmkr'%
quesllonnalrc

C
TABLE 7.1 A (continued)
METHOD OF STUDY USED FOR DIFFERENT ISSUES ADDRESSED AND TIME FRAME OF DATA
COLLECTION
7 1SStIF.S
Other
e~idemioloeicnl
I
Village
i
Cohort study fomghtly 12 June'% M.~-v
* Cross secllonal one llme 3.5 Novcm".% nfld
P*b~.rl'%
rnorbldity survey
Census one lime 3 Aulun'95 0rtober'9~
Urban
s)Tcrtlaq care
hospital
I
Acuie ~llncss one ume 3 ~utua1'9s Ihlohe~'9S
Chron~c illness one hme 12 Jmulq'94 Dtcrmbr'94
Oui pallent weekl) 12 jut'% LIS).Y~
allc~lkl~~cc
! b)Go+l. Chcsl Clinic
Pondichcrr!.
Chrollic li~lless one tlmc 12 J.nu.r)'PJ Ikrm~br'94
I
-
MElllOU
PRWIIENLT
OP
OIISERVATION
1
Ouuiitutivr
I
Fmus group 2
dscuss~ol~s PLyw
May'%
Indcp~h I0 3.5 "Id
Feb"I.q'%
IIItCnlCnS
Case stud) 2 6 JY'y'% Nnmbr'95
Quantilafive
a Structured one time 3 Seplembtr'% November'%
quest~onnnire
Other
e~~idcn~inleaicnl
Ccnsus
one time
I 1110111111
I A l l Elhnorral~hic
Pl\rlEHN
DllRATlON FROM '10
(MONIHS)
Orlnber'95
puo'/itative
hIn)'%
I'ocuq group 2 3.5 MI6
b.b~.1))96
d~curr~o~l~
hfq'96
r I114cplh 10 3.5 "Id
kbroIr'%
lntcnlcns
Quuntitutive Srpurnkr'L Nuvembr'96
I Slructured one lime
- qucsliorulalrc
... ...... continued

I
TABLE 7.1 A (continued)
METHOD OF STUDY USED FOR DEFERENT ISSUES ADDRESSED AND TIME FRAME OF DATA
COLLeCTlON
i
ME1 llUU Y~lIYSILY U l l N PHOM 1 0
OY (MON1116)
OIlLY.H\.Al ION
Olhcr
eoidemioloeical
* Cohort study monthl) 12 J-'% ~.y'?l
51 INELUEHCEOF E(bnwrsohie
7
/ 1L$11U Qualilafive
1 Qualirotive
Focus group 2 3.5 MI*
I
fib,"",'%
mscuss~ons
~ny.96
In-depth 10 lr~ay'%
IIlIcn ICUS
~l',,,,,I;f,,li,~<
Slruclurcd
ollc lllllc
"p",,'"""
Nu,m,"r'%
qucstlonnalrc
I
Olhcr
Cross secuonal
morblbh swe
111 M.4WUAGE Ethnoeraphic
onc lime
one ume
FOCUS group 2 3.5 Fimv.% h1.)'96
&scuss~ons
Indcpth 10
Mld Mq'96
F*h",.,'%
lnlcn ICWS
3.5
Othcr
gidemioloeieal
Census
one tlme
7 ,4up1'% Orlohtr'95

TABLE 7.1 B
ISSUES ADDRESSED BY DIFFERENT METHODS
(~cadcr 4 A group of 9 mamed men ln the
prelcrct~cc In
age between 25 and 50 ycan
ll,tilnj iluldrcn
with chldren
Nutnl~nn and Ihe
A pup
of lO adolescent grls
p~rl ch~id
A group of 10 adolercenl @s
Ilcallh c.m and • A pup
of8 marned uonlcn ~n
lltc prl cltlld
the age between 25 and 45 yeas
i.dilcd11011 and
nlth chlldlcn
illc g~rl chlid
. l)'lll, cILI~~II~
plllcrli or
ih~ldrc~~
li,Ilucr~~c of
IIIC~~~~C~IC 011 lllc
~lrl 'hdd
hlarr~agc
. (lender 10 . Etghl marnwl won~cn bclaoen
prelercncc ~n
23 and 4U years of agc nlllt
h;~! Ing chlldrcn
chldren
Uutr~t~oit and lhc . Two marned men aged 30 and
e~rl child
35 years wllh chldrcn
tlcallh care and
Ihc girl child
tdurauon and
thc g~rl ch~ld
. &lll\ :icllvll~
plllcril ol
chlldrcn
. lllnllcllcc of
ntclrarcl~c on UIC
g~rl chlld
. M;rrr~agc
.... . ... ..conlinued

TABLE 7.1 B(conthued)
\IPllIOIfi
I
1 I\ 1 I K 1 .
OlI\l K\ \ I IOh
I
I
I
I
111 hl > I\l Ol

TABLE 7.1 8 (continued)
ISSUES ADDRESSED BY DLFFERENT METHODS
METllODS
EPIDEMIO~ICAL
ISSUES
NIIMUEROP
OBSERVATIONS/
OBSERYER
1 YPE OP KUWNUEN IS
I C'ENSIIS Gender preference 3063 . Village populaual~
In havlng cluldren
Health care and 1019 Ch~ldren betrvccn
thc girl cluld (Dm
5 and 20 ywrs of
~mn~unt~auon)
age
Educatlon uld the 1019 . Cluldren tctwccl~
grl cluld
5 and 20 years of
ap
Age at n~cnarchc 503 • G~rls tctwocn 5
and 20 years of
age
11 L'VIIOHI 611:~~ . N~~~~~~~ and the 209 8 Cr~~ldren from YY
prl chlld
fam~l~cs that wcrc
randomly sclectcd
from the study
vlllagc
. Health care and
the girl cluld
Educatton and the
g~rl ch~ld
Dall? ~ CIILI~!
pattern In chlldrcn
111 C'ROSSSh(llONA1~ . HCllth arc 811d 1349 . Nu~nberof
~~OUBlt~11 Y
SURVEY the prl child cl~~ldren cnan~~~~cd
(BCG
~n cross sect~onal
~nmiunuatlon)
morb~dty sunc)
Age at n~cnarclie 248 Number of girls
morc (han 13 \ cJrs
of age examlncd
dunng lhc cross
sect~onal
morbldty sunc!
B TERTIARY CARE
IIOSPIL4L
I OI'TPNIPNT Hwlth uarc and I443 Nulilber arg~rls ((>'I31
AT1 liN1)IINCE
(he prl chlld
and boys (750) bet~rcc
5 and 15 )ears of agc
who attendcd thc out
patlent dcp~nmcnl a1
- JIPMER I~osp~Lll

TABLE 7.1 B(coatlnued)
ISSUES ADDRESSED BY DIPFeRENT METHODS
METIIODS NUMBER OF TYPEOF
OBSERVATIONS1 RESPONDENTS
OBSERVER
ACUTE ILLNESS . H-lth are ~d 41 wrls and 39 bqvs
grl child
who were adnullcd
wlh an acutc illness
in WMER hos ilal
CTIRONIC ILLNESS . Health arc and Rccords or 34 girls
Lhe prl child
and 44 boys
who had cercbral
r-
MFKTKT- ~- --~ --- -- - - -
Hcalth care and WI) Rccords or I45 girls
CII~XT cIJ,vIr
the grl cluld
and 155 boys
FONDICHERRY
bctwcen 5 and I5
)ears or agc nho took
Lrwtmcnl for

TABLE 7.1 C
ECONOMIC ISSUES ADDRESSED AND THE
NUMBER OF RESPONDENTS
FROM WHOM DATA WAS OBTAINED
ISSUB
DIRECT COST OF ILLNESS
C O OF ~ ED~ICATION
COST OP CELEBMATIN(; PUBERTY
(.am OF CELEBRATlNG MARRII\GE
OF A GIRL
(UST OF CELEBRATING MARRIAGE
OF A BOY
C.WST ASSOCIATED WITH THE
FIRST CIII1.D BlRTll TO A
DAUGHTER
NUMBER OF
RESPONDENrS
166
143
40
19
10
11

TABLE 7.2 A
RELATIVE DISTRlBUTION OF DIFFERENT
RESPONSES BY RESPONDENTS (~160) TO THE
STRUCTURED QvESnONh'AIRE:
REASONS FOR PREFERRING BOYS
REASONS
NUMBER
(Y. OF "n") tt
Carry the family name 84
(52.5)
Economic support
Shoulder family responsibilities
I0
(6.3)
Funeral rites
Expensive to have girls
Girls will get married and go to
I
another household (0.6)
# These responses include multiple responses from
the sane individual

TABLE 7.2 B
RELATIVE IllSTRlBIlUON OF PIFEERENT
RESPONSES BY RESPONDENTS (11460) TO THE
STRUCTvReD QUESUONNAIRE:
REASONS FOR PREFERRING GIRLS
REASONS
NllMBBR
(Ye OF "n") #
Girls are affectionate 38
(26.3
They help in household work 13
(8.1)
Boys are diflicult to bring up 5
(3.1)
by8 neglect parents 3
(1.3)
# Ther responses include multifile tcsponrs
from the aadte ihdit.idUa1

TABLE 7.3
COMPARISON OF TIME INTERVAL BETWEEN ONSET OF
ILLNESS AND GIVING FLRST HEALTH CARE IN ACUTELY ILL
GIRLS AND BOYS S
TIME GIRLS BOYS CHI oVALUE
INTERVAL n=41 n=39 SQUARE
0 05
>1 day 15 15
36.6% 38.5% 0 18 > 0 05
# Figures in 2d line give % of *n*
Mean delay in giving first health care (girls) = 2.4 (k1.5) days
Mean delay in giving first health care (boys) = 2.6 (rU.1) days
TABLE 7.4
COMAPRISON OF SOURCE OF FIRST HEALTH CARE RECEIVED
IN ACUTELY ILL GIRLS AND BOYS S
SOURCE OF HEALTH GIRLS BOYS p VALUE
CARE 0=4 1 0-39
PRIVATE DOCI'OR
16 20
39.0%" 51.3% > 0.05&
GOVERNMENT
HOSPITAL
5 2
12.2% 5.1% > v 05'
PETTY SIIOP
MEI)ICAL SHOP 5 1
12.2'!6 2.6Y6 > O 05'
REFERNAI. HOSPITAI. 1 2
7..116 5. I % > 0 05'
FA1111 IIFALIWU 2 6
4.9% 15.4% > 0.05'
INDIGENOUS MEDlCIlVE 2 2
4.9% 5.1% > 0 05.
# Figures in Zmd line give % of 'n'
* Fisher's exact tcat
& Chi square test (X2 - 0.70)
S Data imm tertiary care hospital

TABLE 7.5
COMPARISON OF DALLY ACFNITY PATTERN * BETWEEN COHORT OFGIRLS
AND BOYS (510 YEARS) ATTENDING SCHOOL
GIRlS
BOYS
II - 26 11-37
DAILY MEAN SD MFAN SD 'P VALUE pVALIIE .
ACTIVITY (MINUTES) (MINUTES)
PERWNAI.
wASIIINGAND 111 13 113 13 822 17 SIDE
WORK
17 48 18 66 009 >0.05
ST1II)IF.h
(HOME)
13 22 25 43 22.38 c 0.001
SLEEP 611 51 607 52 0.80 >005
# Mean duration of activit) is the mean for the number of children in that group.
There were twelve observations for each child (once a month for one year)
* ANOVA
fg Tuition: Private coaching outride school on payment

TABLE 7.6
COMPARISON OF DAILY ACTIVITY PATTERN BETWEEN COHORT OF GIRLS
AND BOYS (11-15 YEARS) ATTENDING SCHOOL
GIRLS
BOYS
n = 27 n = 42
UAI1.Y M W SD MEAN SD 'F'VALUE pVALUE.
ACTIVITY (MINUTES) MINUTES)
- PERSONAL 119 12 118 12 031 >005
HOUSE WORK 86 93 8 29 287 06 < 0.001
OUTSIDE
WORK
IN< %(I'
GENEMI IN 0 05
# Mean duration of activity is the mean for the number of children in that group.
There were twelve observations for each cbiid (once a month for one year)
* ANOYA
Tultlon. Prlvate coachlng outlldc *choul on paymenl

TABLE 7.7
COMPARISON OF DAILY ACTMTY PATTERN' BEWEEN COHORT OF GIRLS AND BOYS
(16-20 YEARS) NOT STUDYING IN SCHOOL.
GlRLS
BOYS
n=2J 0-24
DAILY MEAN SD MEAN SD 'F' VAI.IIE I VALUE '
ACIIVITY (MINUTES) (MINUTES)
PEHSONAI. 115 28 126 21 31.87

TABLE 7.8
COMPARISON OF COST ALLOCATION OF ANNUAL
CONSUMPTION OF DIFFERENT ITEMS IN THE COHORT
FAMILIES
ITEM AMOUNT COSTRfEAD % OF
(RUPEES) (RUPEES) TOTAL
COST
OTIIER PROVISIONS
VEGETABLES 2,3'1.640 0 417 0 18.7
ENTERTAINMENT 32.856.0 59 0 2.6
CII.OTIIINC: 1.39.800 0 250 0 11.2
OTHERS 2,34,4200 419 0 18.8
'rur,i~, 12.48.2970 2231 0 1oo.o
Number of families = 99
Number of individuals = 560
Average cost per family = RS. 12,609 (f275)I-
Average wnud income per family = Rs. 12,453 (f253)l-

('OMPARISON OY DIHBC'T C'OSI OF ILLNeSS (Ih RUPEES) Ih C0llOHI"OYGlRI.A AhhU
HOIS ACCOKDINC 1'0 DIFFERENT ITeML OVER A PERIOD OF OhE YEAR
ITEM TOTAL %Ok TOTAL %Ok TOTAL */.OF
COST FOR IlAl COST FOR I I COST lOlAl.
(1)br BOYS l)\r In2= 166 cl'S1
gnrlU
bnr=6
MEUICIYL 490 0 51.9 696 0 75.1 1,186 0 63.4
#A lelul I I YJ ~ ~lrlr (p.11~) untl I10 1111yu (hn,; 111s- 20V) fr~lnl YO fn~~~iller (If,) formed the rnhl,rl
and were followed up for one year. Of these, 711 girls Qh) and 96 boys (hnl) from 82 fmmiliu~
(tfi) fell ill and received treatmenl (tn~. 166). Tbe direct cost of illness was ua follows :-
Average cosi per family per year (Totd costltf,) = Rs.191-
Average cost per child I year (Total coat / tn,) =:RE. 91-
Average cost per girl 1 year (Total cost for girls Ign,) = Rs. 101-
Average cost per boy I year ( Total cost for boys /bod = Rs. 81.
Cost per family per year (Total co~tltf~) - Rs.231.
Cost per child I year (Total cod I In,) = Rs.111-
Cost per girl I year (Total cost I I&) = Ra. 141-
Cost per boy 1 year (Total curt I th2) = Ra. 101-

TABLE 7.10
( O~~PARISON OF ANNUAL cosr OF DIFFEREN I' IIEMS(IN RIII~EESI I'ER CIIILD FOR IIIFF-CR-CN I
LEVELS OF SCHOOLING P
-
llEh1 TOTAL ./OOF TOTAL %OF TOTAL -/*OF
COST TOTAL COST IOTAL COST 1OTAI.
(PRIMARY (MIDDLE (HIGH
SCHOOL SCHOOL SC1100L
LEVEL) LEVEI ) LCVLL.)
111 \ 0 0 I1 0 52 50 I0 4 1540 20 J
* Othera : This includes money given us incentive lo children bj the parents to go to school. It ia
erncrall) about Rr.0.SIl- 1.0 per da) for 2 ur 3 dajs in a month
p Source : Data collected fmm the schuul authorities

TABLE 7.11
COMPARISON OF COST INCURRED ANNIIAI.I,Y BY ('OIIORT OF FAMI1.IP.S FOR
DIYYLIHBN'I' LEVBI-5 OY SC1100LINC (('05'1 IN HIJt3YES)
ITEM PRIMARY SCHOOL MIDDLE SCHOOL HIGH SCHOOL
LEVEL LEVEL LEVEL
n=SU n=54 n=3 I
FEES 0 0 2,835 0 4,774 0
BOOKS 0 0
NOTE BOOKS AND
STATlON,\HY
0 0
Out of 39 (1,) fnmilies in the cohort 80 (1,) famrliea had children studying in school and
out of 209 (n,) children in the cohort. 143 (n) ware studying in school.
Average cost of educatlonlfamilylyear (Totnl coaf It,) = R.. 5191-
Average cost of educntionlchildlyear (Total cost In,) = Rs. 2461-
Cost of cducation/family/year (Total cosVt2) = R~.642/-
Cost of educstionlchildlyear (Total cost8J = Ks. 3591-

TABLE 7.12 A
COMPARISON OF ANNUAL RECURRP,NT COST PER INDIVIDUAL AND PER FAMILY ACCORDING TO
DIFFERENT ITEMS (COST IN RUF'EES)
ITEM NO OF NO OF TOTAL COST COSTlFAMlLY COST/lNDIVIDUAL
FAMILIES INDIVIDUALS
' 1 he covl nirdu~atisn prr child fur dlfirnnl Incls oi~chmling am ublsined from the schtwl aulhorlli~~. SIIICP
Ihr csll wag Ihc same fur all chlldren, there was no standard deviatloa
Atcrspr annusl income per famil) RI. 12,453 (+253.0)1-
Alerap per capita income per annum Rr. 2,201 (f36.0)'-
TABLE 7.12 B
(OUI'\HlSV\ OF l 0\1 01 (FLEBH,\TI\(; IJIFFFHEIl SO( IAl. FL NCTIOYS PER FAUI1.Y AhU PIH
IYDl\'II)l~AI (COST 1Y RIIPEESI
-- --
ITEM NO OF NO OF TO1 AL COST COST 1 COST I INDIVIDUAL
FAMILIES INDIVIDUALS FAMILY
hl\KKl,\C;b.
(BOY)
10 10 2.11.0000 23,100 0 23.10(10
(+7.770 0) (i777 0) (1777 0)

TABLE 7.13
COMPARISON OF THE MEAN WORK LOAD IN THE C0110RT
OF CHLLDREN WITH THAT REPORTED IN AN EARLIER
STUDY
(WORK LOAD IN HOURS)
GROUP 59 WEARS) 9-14 (YEARS)
GIRLS BOYS GIRLS BOYS
UNICEF STUDY.
ROHI\L. 5 5 18 7 7 7 0
URBAN 0 8 2 1 4 6 5 7
C IIRRBNI $1 IIUYL
$1 LDl IN6 0 Y 0 s 2 3 1 1
NO1 SIIIVYING 6 0 4 1
* CJNICEF 1990
# Current study (The age groups were 5 -10 years w d 10-15
years)

FIGURE 7.1
Distribution of daily activity pattern in girls
A (5-10 years studying)
rW-k 13.6%)
F
I,
B (1 1-1 5 years studying)
C
(1 6-20 years not studying)
rlmur- (13.0%)

FIGURE 7.2
Distribution of daily actlvity pattern in boys
A (5-10 years studying)
-. (25.3%)
Lolour- (26.0%
0th. (27.4%
Ldmurr (21 .e%
Othu. (263%

FIGURE 7.3
Distribution of work pattern in girls
A (C10 years studying)
B (1 1-1 5 years studying)
Out 11d.rork (15.5%)
C
(16-20 years not studying)
* IG work: Income generating work

FIQURE 7.4
Distribution of work pattern in boys
A (5-10 years studying)
B
(1 1-1 5 years studying)
C
(16-20 years not studying)
* IG work: Income generating work

Summary And Concliusions

SUMMARY AND CONCLUSIONS
8.1 Summary
8.1. f Objectlves, methodology and study area
This comprehensive case study was a~med at assessing the health, education and
social status of school age children w~th emphasis on the girl child. The various Issues
addressed under the health component were, nutrition, spectrum of illnesses and their
causes in school age children, and health seeking patlern. As regards education, the
aspects addressed were, importance of education, school absenteeism, and school
dropout Under the social component, gender preference in having children, nutrition
and health care to the girl child, education and the girl child, daily activity pattern in
ch~ldren, influence of menarche on the girl ch~ld, and marriage were considered
Analysis included the cost involved in household consumption, givlng health care and
education to children, and celebrating tmportant soc~al functions like attainment of
puberty, maniage and first childbirth to a girl in the family.
While school age was defined to be between 5-15 years of age, the girl child was
considered to be between 5-20 years of age as per the defin~tion In the Nat~onal
workshop on the girl child (Mukhejee,l991).
Most of the data were collected from Kedar, a village in Villupuram district, state of
Tamil Nadu, South India. The total population of the vlllage was 3,068 w~th a sex ratio
of 1,004. Of the village population, 21.8% was between 515 yean of age. The
villagers were mostly landless agricultural laborers, cultivators and weaven. Additional

data for certaln Issues were obtalned from a tertlary care hosp~tal (JIPMER) and
Govemment Chest Cllnlc, both of which are located at Pondlcherry, a town In South
lndla
Ethnograph~c and other epldem~ologlcal methods were used to collect data The
ethnographic technlques Included qual~tattve methods such as fours group
dlscusslons, In-depth ~nterwews, key Informant Interview, nonparllclpant observation,
case stud~es, and structured ~nterwew (a quantltattve method) Other ep~dem~olog~cal
techn~ques ~ncluded data collected at the tlme of census from the study nllage, cross
sect~onal morbldlty survey In school, cohort study, records In the PHC and those
malntalned by the VHN The above were from the study nllage From the tert~ary care
hospital (JIPMER), data on spectrum of illness and health seeking behanor In both
acute and chron~c ~llness were collected, and from the Govemment Chest Cllnlc, data
on the treatment recelved for tuberculos~s by chlldren were collected
The study was conducted between May. 1995 and Apr11,1998 The summary of the
flndlngs IS presented below
8.1.2 Health
[a) Nutrition
(I) Ethnographic methods
Both adults and ch~ldren ate the same type of food No speual food was cooked for the
ch~ldren The staple d~et of the people was nce

(ii) Other epidemiological methods
Cross sectional morbidity survey and cohort study
I. School age ch~ldren consumed a d~ethat was s~gn~flcantly deflc~ent In calories,
proteins, vltamlns and Iron
2. The mean he~ght and we~ght of school ch~ldren were much below the standards of.
affluent lnd~ans and the Nat~onal Center For Health Stat~stics(NCHS) The
d~fference became wlder wlth lncreaslng age and was marked dunng the
adolescent penod
3. In chlldren between 512 years of age, 54 5% girls and 60 2% of boys were
malmounshed (p > 0 05 between the genders)
[bl S~ectrum of illnesses and their causes
(I) Ethnographic methods
Most of the people felt that fever, resplratory ~nfect~on, headache and abdominal paln
were the common illnesses In school age ch~ldren Among the respondents to the
questlonnalre (n=160), 95 0% thought that fever was a common illness In school age
ch~ldren. 85 0% thought that respiratory lnfect~on was common Headache was
cons~de~ed to be a frequent illness by 80 0% whereas 53 0% felt that abdominal paln
was common Anemla, angular stomatltls and worn infestauon (whlch were found to be
the commonly prevalent dlsorders on cross secttonal morb~d~ty survey) were not
cons~dered tllness by them The people In general were Ignorant about the etlology of
these dlsorders, most of wh~ch were attributed to water, heat, cold or food

(ii) Other epidemiological methods
Cross sectional morbidity survey of school children
A total of 591 girls and 758 boys were examined clinically In the government school,
Kedar, after obtaining a detailed history about any illness suffered during the prevlous 2
weeks.
3 History
1. A total of 265 (19.6%) children gave a histoly of having suffered from some form of
illness dunng the previous 2 weeks.
2. The common ailments were fever (12.5%), respiratory infection (6.7%), headache
(4 7%) and abdominal paln (2 9%).
3. The mean duration of fever was 3.6 (i 2.8) days, respiratory infection 4.5 (+ 2.9)
days, headache 3.3 (+ 2.8) days and abdominal pain 2.7(i 2.9) days
4. The mean school loss due to fever was 2.1 (i 2.7) days, resp~ratory infection 1.4
(i 2 1) days, abdominal paln 1.4 (i 2.4) days , headache 1.1 (i 1.8) days and
diarrhea 1 5 (+ 2.1) days.
5. There was no significant d~fference between girls and boys as regards the
frequency of d~sorders, duration and school loss due to these (p > 0.05).
=, Clinical examination
1. Out of 591 girls 15 (2.5%) and out of 758 boys, 25 (3.3%) did not suffer from any
illness. The average d~sorder per child was 2.5 for both girls and boys.
2. The important nutntional d~sorders prevalent were anemia (57.1%), riboflavin
deficiency (32.9%), nutntional skln disorders (11.6%) and vitamin A deficiency
(3.1 %).
3. Among the infectious disorders won infestation, was the commonest being
prevalent in 46.4% of the ch~ldren examined. The other infections seen were dental
cal~es (27.9%), skin infections ( 8.7%), respiratory Infections ( 6.0%) and eye

infections (2.7%). Seven children had leprosy and 4 had tuberculosis Five children
had periodontal disease.
4. Cervical adenitia was prevalent in 29.4% of the children, refractive emn in 5.8%,
deafness in 4.5% and congenital malformation in 2.7 % of the children. One child
had rheumatic heart disease. There were 8 children with lameness and 1 child with
stammering. Three children had seizure disorder.
5. There was no significant difference between girls and boys in the overall prevalence
of morbidity or in the mean dlsorder per child (p > 0.05). However, sign~ficant
differences were found in the prevalence of anemia and worm infestation which
were more common in girls (p c 0.05); and vitamin A and riboflavin deficiency, skin
infections, injuries, penodontal disease and cervical adenitis whlch were more
common In boys ( p < 0.05).
6. The mean age at menarche was 13.6 (f 1.05) years.
Cohort study
A cohort of 93 glrls and 116 boys in the age group 5-20 years from 99 households were
followed fortnightly for one year
1. There was a total of 127 and 179 episodes of illnesses in girls and boys
respectively, with an incidence of 1,400 episode of illnesses11,000girls/year and
1,500 episodes of 1llnesses11.000 boyslyear (p > 0.05 between the genders)
2. The commonest illnesses were fever, resp~ratory infection, headache and
abdominal paln wlth an lncldence respectively of 67511,000, 26811,000, 22511.000
and 17711,000.
3. The mean duration of fever was 1.9 (? 1.64) days, respiratory infection 2 9 (i 0.81)
days, headache 1.1 (+ 0.44) days, abdominal paln 1.1 (It 0.49) days and diarrheal
disorders 1.4 (i 0.79) days. No signlflcant difference between girls and boys was
observed with respect to the duration of illnesses (p > 0.05)
4. Most of the illness eplsodes occurred ~n the pre-monsoon (July- September) and
monsoon (October-December) penod.

VHN and PHC records
I. The records maintained by the VHN showed that out of a total of 578 patients
treated during a one year period in the village. 87 (15.0%) were of school age. Forty
four (51.1%) had respiratory illnesses and 30 (34.0%) diatrheal illnesses. Most of
the illnesses were seen in the pre-monsoon penod (July- September). There was no
sign~ficant d~fference in the prevalence of these disorders between girls and boys (p
> 0.05).
2. The PHC records showed that out of an average daily attendance of 146 patients,
31 were in the school age group forming 21.2% of the total attendance.
Tertiary care hospital (JIPMER)
Out of a total of 1,443 children between 5-20 years of age who attended the tertiary
care hospltal over a period of one year, 693 (48.0%) were girls and 750 (52.0%) were
boys. Infectious diseases (32.2%), skin disorders (15.5%), worm infestation (12.3%)
and ear disorders (11.0%) were the Important causes of hosp~tal (outpatient)
attendance
Among the infections, respiratory infection was the commonest.
wnstltutlng 87 5% of all infect~ons
It was thus observed that the health problems in school age children as studled in the
cross sectional morbidity survey, records of the VHN and PHC and tertiary care hosp~tal
were different from what the community perceived as health problems. The cohort
study more or less reflected their point of view.
[cl Health seeklne behavior
(I) Ethnographic methods
For most of the aliments, allopathlc treatment was resorted to. However, the medicines
were often obtained from unqualified sources. Indigenous treatment was glven for

sonie a~ln~ents like jaundice, measles, snake bile and scorplon stings Occas~onally
faith healing was also tried
(ii) Other epidemiological methods
Cross sectional morbidity survey
It was observed that 25 0% of the children went to the local PHC, 18.0% to pnvate
doctors, 11.0 % got medlc~nes from the petty shop, 6.0% got them from the pharmacy
and 1 9% from the compounder. Home remedy was given in 4.5% of the children and
33% d~d not take any form of treatment
Cohort study
Th~s showed that 45 4% of the episodes were not given any type of treatment, 26.0%
were treated by med~cines got from the pharmacy, 14.1% ware treated in the local
PHC, 8 4% by rned~c~nes from the petty shop and 0.05 % by pnvate doctors. Faith
heal~ng was given for 1 eplsode of fever only.
8.1.3 Education
(a) Importance of education
(i) Ethnographic methods
Most of the people felt that educat~on was necessary for both girls and boys,
particularly lor the lalter. Many felt (1551160, 96.840) that educat~on was essential to
bulld the character of their children and also to get jobs. The wllagers generally

expected the school to do everyth~ng for their children and were not very happy w~th
the government school
(11) Other epidemiological methods
1. The overall l~teracy rate over 6 years of age ln the vlllage was 63 0% It was
s~gn~f~cantly h~gher In males (74 6%) than In females (51 7%, p < 0 05)
2. The proport~on of children studying In the relevant age group In the pnmary, middle
and hlgh school sections were 91 0%, 92 0% and 53 4% resped~vely
3. The proport~on of chlldren between 5 and 15 years not enrolled ~n school was
10 5%
jb) School absenteelsm
(I) Ethnographic methods
Although dunng group d~scuss~ons, many parents felt that the common cause for
staylng away from school was playfulness, the structured queshonna~re showed that
only 8 8% ( 51160) felt that playfulness was a cause for absenteeism, wh~le 30 0% felt
that illness was the cause for school loss A few felt that local fun~tlons, housework and
v~s~ts to other places were also respons~ble for school loss
(11) Other epidemiological methods
School survey
A random survey of 226 ch~ldren showed that work was the cause of absenteelsm in
34 1% of the ch~ldren followed by ~llness rn 29 2%, local fesbvals in 18 6%, and vlslts
outs~de the vlllage in 12 4% of children Playfulness was a cause of absenteeism only
In 1 1% of them The school absence was maxlmum In the m~ddle school level There
were sign~ficantly more g~rls than boys who were absent because of illness (p < 0 05)

Cohort study
A total of 54 glrls and 89 boys In the cohort who were In school were followed for one
year The common causes of absentee~sm In them were adverse weather condlt~ons In
50 9%, illness In 14 5%, ws~ts outs~de the wllage In 12 7%, and playfulness In 4 5%
The mean number of ep~sodes of absentee~srn/ch~ld/year was 1 6 (a 6) and the mean
number of school days lost was 15 (11 4) dayslch~ldlyear The mean number of
ep~sodes of school absentee~sm due to ~llness was 0 221ch1ldlyear and that due to work
was 0 12lch1ldlyear The mean number of days lost due to ~llness was 3 2 (G 2)
daysleplsode and due to work was 1 0 (a 5) dayslep~sode No s~gn~ficant d~fference
was observed between g~rls and boys as regards the magn~tude or causes of school
absentee~sm (p > 0 05) It was also observed that out of 110 ep~sodes of absentee~sm,
73 (66 3%) occurred dunng the monsoon penod, 10 (9 1%) In the post-monsoon, 19
(17 3%) In the pre-monsoon and 8 (7 5%) In the summer penods
jc) School dropout
(I) Ethnograph~c methods
Most of Ihe parents wanted the~r ch~ldren to complete school~ng They (1491160, 93 8%)
felt that poor performane In school was the most common cause for dropouts They
sa~d that the ch~ldren themselves dec~de not to go to school and there was noth~ng that
the parents could do about ~t However. 80 6 % felt that poverty was also an Important
factor In ch~ldren dropp~ng out of school Some felt that g~ds were generally taken away
from school when another ch~ld was bom, In order to take care of the new arnval Most
of them were of the oplnlon that menarche was not an Important cause for girls

stopplng from school They felt that some may however use ~t as an excuse to stop
ttielr daughters from school d they cannot afford educatlc~n
(ii) Other epidemiological methods
Cohort
Of the cohort of 93 girls and 119 boys, there were 29 girls and 24 boys who liad
dropped out of school at varylng penods Poverty (44 8%) was the most Important
cause of dropout among girls, whlle ~t was poor performance (54 2%) among boys In
addltlon to poverty, the need to help at home (20 7%). phys~cal handlcap (6 9%) and
menarche (6 9%) were the other causes of dropout among g~rls Next to poor
performance, poverty (37 5%) was an Important reason for dropout ln boys
Census
Out of 430 glrls and 462 boys between 5-20 years of age who were enrolled ~n school,
90 (20 9%) girls and 80 (16 6%) boys respect~vely had dropped out (p > 0 05) Most of
tile dropout In girls as well as boys occurred In the prlrnary school le~el
School record
Uurlng the academ~c year 1995-1996, 89 (4 7%) chlldren out of a total of 1.881
dropped out The dropout rate In g~rls (3 7%) was not s~gnlficantly different from that In
boys (5 4%, p > 0 05) The dropout for girls mostly occuned In the pnmary and the
m~ddle school levels whlle for boys 11 was ~n the mlddle and h~gh school levels
8 14 Socioeconomic
]he Issues under thls aspect, considered ch~ldren In thelr home mll~eu wh~ch was taken
as the snclal context

la) Gender preference in havina children
11) Ethnographic methods
Structured quest~onnalre showed that while many (751160,46 9%) people preferred to
have both a boy and a girl some (25 6%) preferred to have only a male ch~ld A few
(15 0%) d~d not m~nd a chid of any sex, while yet another few (12 5%) preferred to
have only girls Boys were preferred malnly for ewnomlc support and to carry on the
fan~lly name The value of girls In looklng after the parents when necessary and help~ng
them In housework was apprec~ated by some people The sex ratlo of 1,004 In the
village supports the fact that gender preference was not strong In thls part of the
country
lb) Nutrlt~on and the girl child
(i) Ethnographic methods
The vtllageis d~d not glve any speclal d~eto thelr sons Many (891160. 53 0%) felt that
whoever was hungry should eat f~rst Some people felt that boys were generally fussy
about food whlle g~rls were more accommodat~ve
(11) Othe~ epidemiological methods
There was no d~etary dlscnmlnatlon agalnst girls ether In the quallty or quant~ty of food
d~spensed Although both girls and boys consumed much less than the recommended
values of nutrients, no slgnlflcant d~fference was observed between them (p > 0 05)

jc) Health care and the air1 child
(i) Ethnographic methods
All of them felt that attentlon should be glven to a slck chlid whether it was a boy or a
girl They do not glve d~fferent care for boys and girls. They felt that a chlld, whether
boy or girl was very preuous
(ii) Other epidemiological methods
Data from rural area
3 Immunization
1. From the data collected along wtth the census ~t was observed that out of 503 glds
and 516 boys between 520 years of age, 426 (84 7%) glds and 465 (90 12%) boys
were completely ~mmunlzed w~th DPT (p < 0 05)
2. In the cross sect~onal rnorb~d~ty survey In school, 217 out of 591 girls (36 7%) and
274 out of 758 boys (362%) had endence of ~mmunlzatlon w~th BCG vacclne (p >
0 05)
3 Morbidity
There was no s~gnlflcant dlfference In the overall morb~dlty between girls and boys In
the cross sectional morbldlty survey In school as well as In the cohort study
3 Attention in sickness and type of health care
No slgnlflcant dlfference was observed In the type of health care glven to girls and boys
as per school survey and cohort study (p > 0 05) In the cohort study, ~t was also
observed that 7 out of a total of 127 eplsodes (5 5%) of ~llnesses In glds and 13 out of
179 (7 3%) ep~sodes of illnesses In boys were glven medical attentlon after a delay of 2
days llom the onset of lllness (p > 0 05)

Data from tertiary care hospital
3 Hospital attendance
Out of 1,443 children between 515 years of age who attended the outpatlent
department of JIPMER hospital, 693 (48.0%) were girls and 750 (52.0%) were boys
showing that there was no appreciable gender difference In the hospital attendance
rate in this area.
3 Attention in acute illness and type of health care
Out of 41 girls and 39 boys from whom data were obtained regarding the treatment
given from the time of onset of illness till they reached the tertiary care hospital, no
s~gnificant difference was observed between the two genders either in the time interval
between the onset of illness and the first health care given or the type of first health
care given to them. The mean delay in seeking medical help in girls was 2.4 e1.5)
days and in boys, 2 6 @2 I) days (p >0.05)
2 Attention in chronic illness (cerebral palsy)
A total of 78 case records of ch~ldren w~th cerebral palsy were analyzed regarding
follow up care given to them Out of 34 girls. 9 (28.5%) did not come for any follow up
at all, while the corresponding figure for boys was 16 out of 41 (36.4% p > 0.05). It was
also observed that 15 out of 34 girls (44.1%) and 9 out of 44 boy's (20.5%) had
completed their full course of follow up (p < 0 05)

Data from Government Chest Clinic, Pondicherry
3ut of 145 girls and 155 boys studled, no s~gnlflcant d~fference was observed between
them w~th respect to the followup and complet~on of treatment for tuberculosis ( p >
0 05)
jd) Education and the aid child
(I) Ethnographic methods
Most (1541160, 96 3%)of the respondents to the St~Ct~red questlonnalre felt that
education and jobs were necessary for girls Only a few (3 8%) felt that jobs were not
necessary for them About 71 9% of the respondents sa~d that they would perrn~thew
daughter to go outs~de the vlllage for study~ng or worklng However, many people
(35 0%) were not wllllng to spend too much money on the~r daughter's educat~on
because they would anyhow have to spend on her marnage, while 80 0% were wllllng
to do so for a boy They felt that educat~on was more important for a boy because he
had to get a job and earn money A majonty (99 4%) felt that a glrl should contlnue mth
her schooling afler rnenarche
(ii) Other epidemiological methods
Census
1. More boys (93 4%) than girls (85 5%) were enrolled In school (p < 0 05)
2. The proportion of girls studylng in the pnmary (75 1%) and m~ddle school levels
(71 3%) were s~gn~f~cantly less than the corresponding ftgures for boys which were
86 5 % and 91 7% respect~vely (p < 0 05) There was no d~fference In the pmport~on
of yrls (54 4%) and boys (52 4%) studylng In the h~gh school level (,I > 0 05)

3. Among the vlllage population over 20 years of age, the proporbon of males who
had completed college and hlgh school education were 50% and 21 0%
respectively and the corresponding flgures for females were1 3% and 6 9%
respectively (p < 0 05 for the genders)
Cohort
In the cohort, the propodlon of boys studylng In school (74 8%) was significantly more
than that of glris (56 3%, p < 0 05)
le) Dailv activity pattern
(i) Ethnographic methods
Most of the respondents to the structured questlonnalre (1331160, 83 1%) felt that only
girls should help In housework While 26 8% considered that it was trad~t~onal for girls
to do housework. 8 8% felt that they should be tralned In housework because ~t will help
them later on, when they get marned However, some (16 9%) felt that boys should
also share the housework Some adolescent girls said that they were annoyed with
the~r parents for maklng them do most of the housework Whlle some boys agreed that
thelr s~sters did more work than them, others felt that they did all the hard labor whlle
thelr sls!ers relaxed at home Most of the lelsure time vcas spent by boys In golng out
or for anemas, whlle glris stayed at home or went to the local temples
(11) Other epidemiological methods
Cohort
1. The mean work load In girls Increased from about 0 9 hours per day to about 6
hours per day wlth Increasing age and in boys, ~t Increased from about 0 5 hours
pe, day to about 4 1 hours per day Although at all ages, the work load In girls was

hlgher than In boys, the difference was slgnlflcantly hlgher only between 510 years
of age
2. About 45 0% of the work wmpnsed housework for girls, whlle for boys more than
90 0% of the work lnduded outslde and Income generabng work Boys were also
found to help In housework although to a small extent
3. Girls spent slgnlficantly more bme than boys In studles In spite of dong more work
(p c 0 05) Both glrlr and boys had enough leisure and t~me to sleep
In Influence of menarche on the status of the girl child.
(I) Ethnographic methods
People felt that a girl should be restricted In her actlvltles and controlled In her behawor
after menarche Most (115/160. 72 5%) people thought that restnd~on was needed
because others will say sornethlng ~f she was not, and a few felt that her rnarnage
rnlght be affected The average age of menarche was 14 3(11 3) years After
attalnrnent of rnenarche, the girl's movements outslde the house were very much
restricted
(11) Other epidem~olog~cal methods
Dunng the cross sechonal morbldlty survey, ~t was observed lhat out of 248 girls who
were 13 years of age and above, 42 3% had attalned menarche and were wntlnulng In
school Thls showed that menarche d~d not wnslderably affect a girl's schoollng
(I) Ethnographic methods
Most of the respondents to the structured questlonnalre (121/160,75 6%) felt that a gld
should get marned after the age of 20 yean A few (24 4%) felt that they should marry

efore 18 years of age because people would say something It was not nlce to have
an unmamed girl In the house Most (85 6%) consldered money to be the most
II lportant requlslte for a glrls milrnage
All of them felt that a boy should get marned after 25 years of age so that he will be
respons~ble enough to look after the famlly Many (55 6%) felt that havlng a job was
very essential for a boy to get rnarned while some (32 5%) felt that good conduct and
character were also necessary Some people consldered that hanng a slster In the
rnarnageable age was another reason for a boy not gettlng mamed
(11) Other ep~dem~olog~cal methods
Out of a total of 136 glrls between 15-18 years of age in the vlllage only 10 3% were
mamed and not a angle boy below 21 years was marned
jh) Cost analysis
(I) The average annual Income per famlly In the cohort was Rs 12 4531- (G53 0)
(11) Cost of illness
The average dlrect cost per eplsode of ~llness/chlld was Rs 111-(+1 5) There was no
slgnlflcant difference between glrls and boys (p > 0 05)
(111) Cost of oducatlon
The cost of educabon per chlldlyear was Rs 151- In the pnmary school level In the
mlddle and h~gh school levels the cost was Rs 502 50 and Rs 7541- respcztlvely

(lv) Cost of household consumption and celebration of social functions
The average expendlture on household consumpt~onlfam~ly In the study nllage was Rs
12609 (Q75 0) per year The average annual household expend~ture on health and
educat~onlfam~ly were Rs 191- (Q 0) and Rs 6431- (fl 0) respectively The average
expendlture Incurred on celebrating Important social functions lhke atta~nment of puberty
and the first chlld birth to a girl In the famlly were Rs 3,1771- (+48 0) and Rs 5.8181-
(5222 0) respectively The average expenses for the mamage of a girl was Rs 31,1761-
(i1.021 0) and of a boy, ~t was Rs 23,1001- (i777 0)
8.2 Conclusions
The conclusions reached wlth respect to the specific objectives of the current study
(Chapter 2) are as follows -
8 2.1 Health
(a) The Intake of vanous nutnents by school age chlldren was much below the
recommended allowance and malnutntlon was wldely prevalent In them
(b) Anemla, vltamln A and nboflann defluency and worm lnfestdtlon appeared to be
Important causes of morbld~ty In these chtidren
(c) The health problems In school age chlldren as perceived by the commun~ty were
different from those revealed by the cross sect~onal morbldlty survey
(d) The people were Ignorant as regards the etiology of many of these disorders
(e) Many of the illnesses were untreated
(f) Allopathy was the most commonly followed system of therapy
(g) There was no gender d~fference as regards the overall morbldlty or the type of
treatment given to the chlldren
8.2.2 Education
(a) People were aware of the lnlportance of education, and wanted to glve the best to
thmr chlldren, partlculariy boys Although most of the chlldren were enrolled In
school, there were more boys than girls among them

(b) School absenteelsm was not a very Important factor affecting educational
attalnment In chlldren
(c) Adverse weather condltlon was an Important cause of absenteelsm Work and
Illness were other causes of school absenteelsm
(d) The dropout rate was not slgnlflcantly different between glI-s and boys In glrls,
poverty, and In boys, lack of Interest and poor performance were the ~mportant
causes of dropout
8.2.3 Socioeconomic
(a) There was no strong preference for sons In the study nllage The girl chlld In the
study area appeared to enjoy the same love and affection from her parents as the
boy
(b) There was no gender dlscnmlnatlon In glnng health care to a slck chlld
(c) There was no d~etarj dlscnmlnatlon agalnst a girl
(d) The total work load on a girl was marginally hlgher than her male counterpart ~n all
ages In the older age, she also spent more t~me In studles than a boy,
(e) On account of strong cultural and economlc pressure, she was glven a low pnonty
In the ntal area of educatlon
(I) I lor rilnvotilotlls nrid ncllvlllos woro rosltt~lod WIIIIIII n tIurrow CI~LIU r111~1r I~~O~ILI~LIIO
However, her schooling was not affected appreciably
(g) An unmamed girl was considered a soc~al burden and parents gave pnonty to her
mamage rather than education
(h) The dlrect cost of health was very much less than the cost of educatlon
(i) Slncc the average household consumpt~on cost of a famlly (recurrent expenses)
was more than thelr average income, the villagers were always In a negatlve
economlc balance Therefore, any added expenses ~ncurred by way of glwng
educatlon to thelr chlldren and celebrating Important social events lhke attalnment of
puberty, rnarnage etc were add~tlonal causes of economlc burden on the family

RECOMMENDATIONS
Based on the flndlngs of the current study, the follow~ng recommendat~ons are made In
order to Improve the health, education and soclal status of school age chlldren wth
emphasls on the g~rl chlld -
S.1 Health
The prevalence of undemutntion, anemla, vltamrn A and nboflavln deflclency can be
reduced by impronng the Intake of the respectwe nutnents by way of health educatlon
andlor supplementatlon
The existlng programs could be modlfied to pronde
supplementatlon as suggested below
The energy supplementatlon provlded by the mid day meal program could be
enhanced particularly In the mlddle and hlgh school levels
Vltamln A prophylaxis program (admlnlstenng 6,00,000 I u of vltamln A In 011 every 6
months to chlldren between 1-6 years of age and half the dose to Infants between 6
months and one year) can be expanded to Include ch~ldren up to 15 years of age
Iron and fol~c acld supplementatlon which 1s currently belng glven to chlldren up to
the age of 12 yean should be glven to adolescent chlldren also
Penodlc dewoning (I e hce a year) could be done by school teachers
Health educatlon of the children as regards personal hyglene will reduce the
prevalence of dental canes and skln lnfectlons
Education of the community wlth respect to etlology , prevention and management
of the Important health problems In school age chlldren like nutntlonal and
lnfectlous disorders will Improve the health status of school age chlldren

9.2 Education
The follow~tig recommendations are made with a view to increase the enrollment rat0 ~n
chlldren and to reduce the dropout.
The community should be motivated to get more involved in the~r children's
education by way of frequent interaction with school teachers.
The education system has to be reviewed and revised, to make 11 more Interesting
and suitable to children in a rural area.
The school authorities should not be very rigid in maintaining discipline. Occasional
late coming because of preoccupation with domestic work should be condoned. At
the same time parents should also be educated about the Importance of punctuality
and discipline
The school physical infrastructure has to be improved so that children can attend
school even during inclement weather conditions.
Free education should be given to girls upto high school level
The incentives that are now given for girls who complete the education should be in
such a way that they benefit the g~d as well as her family soon after completion of
education or as they move from class to class and not several years kter.
9.3 Social
The need of the hour IS to make the community aware of the necessity to Improve the
educational status of the girl child. Education takes place not only in school, but also
outside it. People should be mot~vated to permit a greater degree of movement to girls
outside their homes Since the educat~onal status of the gid is also indirectly linked with
the financial burden in connection w~th her maniage, active campaigning must be done
to reduce the financial burden These changes require a gradual change in the attitude
of the community towards a ~II-l child and can be brought about only by tireless
education of individuals and the community.

9.4 Recommondatins for future research
Slnce thls was only a case study In a stngle wllage, much more work requtres to be
done on larger sale before general~stng the flndlngs The research also has to be
focused on spectfic Important problems In school age children brought out In the
current study llke malnutntlon, school dropout and educatlonal status of the girl chtld
Thls study has shown that school age chlldren have slgnlflcant morb~dlty Their
educatlonal and soual status are not satisfactory Further research IS required to see
whether lntetventfon In the field of health or improvement In the educatlonal system
would substantially alter the outcome It IS also very ~mportanto find out the type of
tntervent~on to be used at the community and the lndlvldual level in order to Improve the
soclal status especially the educatlonal status of the gtrl chlld

- - --
B i6fiog rap hy

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Epldemlology of gollre In school children in rural Kashrnlr (Pulwmme district). Journal of
International Medlcal Sclences Academy, 10, 13-1 4.

* Not to be Rlled In the fleld
" Codes Matitd Stalus Mzmarrted UM=unmrned S=separaled W=w~dowed Ed Sla:ila Wnte adual educabonal slatus Ill=~lliierale &cupatan
Wrne actual occupatton NO=nat occup~rd Rsdencl Stalus P-residlng in household NR=not rewdlng R_elalans W=de H=hucbnd Dzdaughter S=son M=mather F~father
FIL=father-m-law MIL=rnother In law B=brother S=sisler GS-grandson GD-granddaughter

School chlldren nlorbldily SA Form 2 Morbldlty Survey
I General lnfor~nat~on
1 ldentilicatlon data Date
Name Aye Sex ID No
Father 4 Nar.1-
Mothers Name
Strp-t
Household No
2. Place of exarr~tr~ation ...................... School \ Home
Il al II-~IIIL, :,I i' whe 111. 1 .
i I iI~?eril~c~ \ Nut enrolled
3. Information frorn teaclret
Is this r Iilirl soifr3rrln lr,vr> any rnoibid~ty Yes \ No
If yes !lie rlatlirr of rnoibldlty 1) .....................
2) ..............
11. Cll~lic:>l blislry
1. Hnstory of illr~ess dtrrlrry tllr psbl 2 weeks . . ..Yes \ No
If YP? , tljr I?:\IIIII. of IIIIIPT~', i l l t llln!!l~~a \ nbd pain \ fever \ I~cndnche
,',.i2 '! ear \ skin \others
Ccta~ls of ~llness: Duration ......
Sgwerily . . . . . mtld \mod \ sev
hospitalhsed
Yes \No
No, of school days lost ....................
others
2. History 01 passing worms during the past 1 month . Yes \ No
Hislory of passlrq worms durmg the past 6 months . . .Yes \ No
(excludtilg the prevlous one month )
If Yes, the nature of warms passed . . . . Big \ Small pink \ whlte
3. History of taking treatment for chronic diseases ..... Yes \ No
If Yes, for what disease? ...........................................

School children-Girl Chlld S.A Form 2
Morbldlty survey (contd.)
Ill Cllnlcal Exarnlnatlon
Ht cms Wt kg%
1 Eyes R N \ Abn If Abn specify
xerosis \ 0, spots \ Conjunctivlt~s \
L N \ Abn If Abn specify
xerosjs \ B spots \ Conlunct~v~tis \
1 1 ' iurirlus R N \ Abn If Abn specffy
L N \ Abn If Abn spec~fy
1 2 Viston R Normai \ lmpaired If impalred specify
L Normal \ lmprured If impa~red specify
2 Ears R N \ Abn If Abn speclty d~scharge \
L N \ Abn If Abn specify discharge \
2 1 Hearing R Normal \ Impaired If lmpalred speclty
L Normal \ Impaired If lmpa~red specify
3 Nose N \ Abn If Abn specify
4 Oral cavity N \ Abn If Abn spectfy
caries \ perlodonla1 dtseaas \ angular slornatllls
glosalls \ pallor \ poor hygelne \
4 1 Speech Normal \ Impaired If ~mpaired spec~fy
5 Ha~r N \ Abn If Abn speclfy
pedlculosis \ ~mpetigo \ seborrhea
unhealthy \
(i Nalls N \ Abn
7 Skm N \ Abn
If Abn spc\cify
paronyctlla \ kolianychia \
M Abn specify
scabies \ impetigo \ phrynoderma
dry nncl scnly \
8 Anaemla Absent \ Present
*This will be done only for selected cases

School children -Girl Child S. A Form 2 Morbidity Survey (contd. )
9 BCG Scar Present \ Absent
10 Neck
N \ Abii
If abn spectty
goitre \ edenttls \stnus \
11 CVS
N \ Pbn
If abn spectfy
RHD \CHD \others
12 Congen~tal malform Absent \ Present If present spec~ty
13 Lameness Absenl \ Present
14 Fiesplratory Systern N \ Abn If Abn npacib
URI \ LRI \ Slnusttlr \ Asthma \ Tonsllit~a
15 Abdomen N \ Abn If Abn speclty
splenornegaiy\
hepatornegaly \
16 Generaltsed lyrnphadenopathyAbsent\ Present
17 Extn. Gen~lalla N \ Abn If Abn specify
( By hlstory )
78 Brsaar N \ Abn If Abn =pacify
19 Menustrual hlstory
Age of Menarche
Periods
Dysrnenhortea
Menustrual Flow
years
Regular \ Irregular
Absent \ Present
Normal \ Abnormal
20 Vaginal discharge Absent \ Present
IV
Additional lntormatlon Obtalned From:
2. PHC :-
3. Peers:.

School children Girl child S.A
ID. No ..................
Form to be filled up during first visit
Name of the ch~ld Age Sex Fathefs Name
Street House No. Date
1 Cost of education ~choo~ Govt /Private
School fee
Cost of books
Cost of ~~oieborrks
RS
RS
Rs
Other statlonary Items Rs . .
Sct~ool dress Rs . ..
Others Rs ... .
I1 Cosl of Social Customs
- - - -
Travel Self
Others

I11 Cost of gifts received (approx)
I Kind: Jewels Clothing Others 2. Cash
1V Source of expenses
Source
Savings
Borrow
Amount (Rs)
Details
Pledge
Sell
-.
Others
V Housp Hold Consumption Cost
VI Major Expenses during the last one year

Form to be filled up during follow up visits
Morbidity, School absenteism, Diet and Activities
Name Age Sex ID. No Date
Father's Name Sbeet House No. Msit No.
I. ILLNESS
1. History of Illness during the past two weeks Yes /No
2. If yes, the nature of illness
3. Details of illness
Fever \ Resp ! Dlarrhea \ Dysenteiy !
Abd.pain \ Headache \Eye \Ear ! Skin
Duratlon
Severity
mild \ mod \ sev
Hospital~sed Y\N
No, of school days lost
4. Type of health care rece~ved
I
Aliopalily
11 Home r~medy
III
iv
v
Faitti Heallng
Other systerns
No treatment
if (I) the11 a) Medicines avaliable at home b) Medlc~ties bought al petty shop c) Medlclnes bought
~n a pharmacy d) Med~c~ties prescrlbed by a Govl doctoi
e) Medlclnes prescrlbed by a prlvate doctor
5. lllterval between onset of illness and health care ............. days
6. Reasons for delay in health care, if any
2. Cost of illness
Medicine Rs. Consultation fees Rs. Travel Rs.
Investigation Rs.
Hospltnlisat~oll Rs.
Cost of accompanying person (Travel, food and loss of income) Rs.

!. School attendance (Recall of two weeks)
Reasons
lterrr Morn~ng Noon Evening Night lnbetween
Tl'l,',
Others

h. I'arliril,nlio~~ ill 1111usrhol drlivities ( Recdll of previous day's aclivilies 6 d.~n. Lo 1, p.111.)
as 11 a hol~day
YIN
Act~vity
Morning
From To
. --- . .- . -- .. .
Brusli~iyle~lli i wn\ll . tb,jlh
From
Noon
To
Eve / Nighl
From
To
W,35tl rl

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