A study of the health status of early adolescent girls residing in social welfare hostels in Vizianagaram district of Andhra Pradesh State, India.Introduction/Background
Adolescent girls form an important vulnerable sector of population that constitute about one-tenth of Indian population . Under-nutrition among adolescents is a serious public health problem internationally, especially in developing countries . Early adolescence after the first year of life is the critical period of rapid physical growth and changes in body composition, physiology and endocrine . The Ministry of Women and Child Development is significantly involved in the issues of nutrition and development of children, particularly girl children. The scheduled castes and scheduled tribes have been identified as two most disadvantaged groups of Indian society needing special attention . Empowerment of the hostel Girl is necessary to help her cope with the changes and promote awareness of health particularly nutrition and reproductive health, so as to break the intergenerational life cycle of nutritional and gender disadvantage and provide an enabling and supporting environment for self-development . Social welfare department, with respect to the socioeconomic status of Scheduled Caste population and socio academic profile of the scheduled caste children, has been maintaining hostels as a pro-educational measure. These hostels serve as homes away from homes at places where schooling facilities are available. The girls stay more than 8 years in these hostels. Health care of these girls in the hostels is of utmost importance because the children in the school age (10-15 years) are in a period of growth and development when optimum nutritional and health care is essential. Adolescent girls health covers nutritional status, morbidity, and reproductive health. During the period of adolescence the nutrient needs are the greatest . The girls are usually physically stunted a manifestation of chronic protein energy malnutrition. A large proportion of adolescent girls suffer from various gynecological problems, particularly menstrual irregularities such as menorrhagia, polymenorrhea, oligomenorrhea, and dysmenorrhea. In Andhra Pradesh, the welfare Programmes for the Scheduled Castes are looked after by the Education and Social welfare department. These institutions run on par with hostels and are being run in summer vacation also . The role of these hostels in their education advancement is considerable . To achieve this objective, the Government of Andhra Pradesh has started a large number of social welfare hostels and at present, there are 2313 hostels functioning in the A.P state with scheduled caste children comprising 70% of the hostel inmates . Various base- line surveys also revealed that the health, nutritional and educational status of adolescent girls are at sub-optimal level . The data regarding the nutritional status & morbidity status of the early adolescent girls in social welfare hostels are sparse, despite the usefulness of such information in the management of hostels and upliftment of these groups . In this context, the present study was taken up among early adolescent girls residing in the social welfare hostels in urban area of Vizianagaram District. This study focuses on nutritional & reproductive status of early adolescent girls.
Aim and Objectives
1. To study the health status of early adolescent girls residing in social welfare hostels of Vizianagaram city, A.P.
2. To assess the Nutritional status of the early adolescent girls residing in the hostel.
3. To study the Morbidity pattern among the early adolescent girls in the social welfare hostels.
Study design, study population and Sample size:
Cross sectional study was conducted from June 2010 to September 2010 among Children residing in two social welfare hostels for scheduled Caste girls. It is a field practice area of Department of Community Medicine, Maharajaha; Institute of Medical Sciences, Vizianagaram. A total of 420 girl's children formed the study subjects. Permission from the Deputy Director of Social Welfare was obtained for conducting the study. The wardens were interviewed and, hostel registers were looked into to secure information regarding the number of residential children. The medical officer along with house surgeons of the urban Health centre provides medical checkup and treatment for children once in a month. Those requiring specialist treatments will be referred to district hospital. Data regarding morbidity status was collected using a pre-tested proforma. At the first visit during June 2010, every child was examined physically from head to toe and deviations from normal, if any, were recorded. Enquiry was made about the health ,reproductive problems and occurrence of any ailment during previous two weeks.
Nutritional Status [right arrow] Nutritional status of girls was assessed by Anthropometric measurements viz height, weight, BMI.
Anthropometry Height--Stadiometer (measuring rod) capable of measuring to an accuracy of 0.1 cm was used to assess height of the subjects. The subject was made to stand without foot wear with the feet parallel and with heels, buttocks, shoulders, and occiput touching the measuring rod, hands hanging by the sides. The head was held comfortably upright with the top the head making firm contact with the horizontal head piece.
Weight--A portable weighing machine with an accuracy of 100gms was used to record the weight of the girls. Checking the scale with a known weight was done frequently and adjustment to zero was done every time for accurate reading. A girl were instructed to stand on the weighing machine with light clothing and without footwear and with feet apart and looking straight and weight was recorded to the nearest value.
Body Mass Index (BMI)--BMI was calculated using the formula (BMI =Weight in kg/height in [m.sup.2]). The girls were categorized into Various grade based on BMI according to WHO International Standard [11,12,13]. Hat is, Grade 3 thinness (BMI < 16 kg/[m.sup.2]), Grade 2 thinness (BMI 16-16.9 kg/[m.sup.2]), Grade 1 thinness (BMI 17-18.49 kg/[m.sup.2]), Normal (BMI 18.5-24.99 kg/[m.sup.2]), Overweight (BMI 25--29.99 kg/[m.sup.2]) and Obese (BMI >30 kg/[m.sup.2]) . The girls were categorized into Various grade based on BMI according to National Standard , undernutrition (BMI<18.5 kg/[m.sup.2]), Normal (BMI 18.5-23.5 kg/[m.sup.2]), and Overweight (BMI >23.5 kg/[m.sup.2]).
Data Analysis: Data collected was entered in Microsoft Office Excel and analysed by using SPSS Version 16.0.
Study instruments: Pre-designed, pre-tested, semi-structured questionnaire, stethoscope, Weighing machine, measuring tape etc.
Results / Findings
A total 420 girls were studied. Of that 37.4% (157) were in the age group 13 years. Followed by 26.9% were in age group 14 years, 18.6% were in age group 12 years, 9.8% were in age group 15 years and very few that is 5% and 2.4% in the age group 11 and 10 years. (Table -I)
In the present study according to WHO reference standards, 56.4% (237/420) girls were under-nourished (BMI [less than or equal to] 18.5). The Girls suffering from chronic energy deficiency grade I, II and III were 25.2%, 15.2% and 16 % respectively. 12 (2.9%) was found to be overweight and none of the girls was found to be obese. According to the new guidelines by the Government of India as per the dianostic cut-off values the 56.4 % was found to be undernourished while 5.8 % was found to be Overweight (BMI >23.5 kg/[m.sup.2]). (Table-II) 126 out of 420 (30%) were showed clinical anaemia, 114/420 (27.1%) were having dental caries, 70/420 (16.7) were having reproductive problem (dysmenorrhoea), 67/420 ( 16% ) were skin problem, 4 % Eye problem( defective vision & refractive errors), 2.4 % were having URTI and 2.1 % ENT problem. (Table III)
Undernutrition is documented public health problem contributing substantially to children's survival. There is scanty information on the nutritional status of girls residing in social welfare hostels. Therefore, there is a need to study the health problems among these girls and to develop a database from different parts of the country.
The results of the study are discussed below. The underfed still outnumber the overfed in the developing world among Asian, African and Latin American populations. In spite of the economic development in the region, undernutrition remains an important public problem in many Asian countries . Undernutrition is a significant problem and continues to be a cause of morbidity and mortality among children in developing countries like India [17, 18]. The recent study of Cole et al  has stated that undernutrition is better assessed as thinness (low body mass index for age) than as wasting (low weight for height). Prior to this report, there were no suitable thinness and overweight/obesity cutoffs for 2-18 years age group [12, 13]. The uses of these new cut-off points are suggested to encourage direct comparison of trends in childhood thinness and overweight/obesity worldwide. Moreover, these cut-offs provide a classification of thinness and overweight/obesity for public health purposes at the National and International level.
In the present study according to WHO reference standards . 56.4% girls were under-nourished (BMI [less than or equal to] 18.5 kg/[m.sup.2]). Girls with thinness grade I, II and III were 25.2%, 15.2% and 16 % respectively. Out of the total 420 girls, 12 (2.9%) was found to be overweight and none of the girls was found to be obese. According to the new guidelines by the Government of India (ICMR)  as per the diagnostic cut-off values the 237/420 (56.4%) was found to be undernourished while 5.8 % was found to be Overweight. In a study conducted by Kapil et al.  8.1% were CED grade I, 6.65% were CED grade II and 78.8% were CED grade III. In a study by Raheena Begum  in Kerala, 53% in 14 years age group and 33% in 15 years age group were having BMI <18.5 kg/[m.sup.2]. In a study by Deshmukh et al.  CED was found to be 75.3%. In a study by Meenakshi Kalhan, 80% of the girls were under-nourished (BMI <18.5 kg/[m.sup.2]) . The study of urban slum girls in Dhaka reported prevalence of thinness 17% . Various authors have reported the prevalence of thinness among adolescent girls to be 14.7% , 30.1% , 41.3%  and 59% . In a study among adolescent girls in Rajasthan, 6.5% of the girls were found to have a BMI of more than 18.5 . Nurul Alam et al. found out that 26% of the girls were thin, with body mass index (BMI)-forage <15th percentile), 0.3% obese (BMI-forage >95th percentile), and 32% stunted (height-for-age [less than or equal to] 2 SD) . According to Lazzeri G et al., the prevalence of thinness declined from 9.8% to 8.7%, and the prevalence of normal weight from 77.0% to 71.6%, while the prevalence of overweight rose from 13.3% to 19.7% . In a study by Pascal Bovet et al. prevalence of thinness was 21.4%, 6.4% and 2.0% based on the three IS cut-offs and 27.7%, 6.7% and 1.2% based on the WHO cut-offs . Saxena Y et al. prevalence of thinness was 56.25% . Study conducted by Shivaramakrishna, 73.3% girls were under-nourished (BMI< 18.5). The prevalence of chronic energy deficiency based on BMI(grade I, II and III) were 23.0%,28.3%, and 22.2 % respectively. Study by X Du H Greenland et al Using a modified Chinese reference, the rate of low body weight (BMI<18) was 32.2% . Yustina Anie Indriastuti Kurniawan et al. about 50% were underweight and stunted indicating the presence of acute and chronic malnutrition.  Reports from India, Bangladesh, Nepal and Myanmar show that 32%, 48%, 47% and 39% adolescents respectively are stunted, and 53%, 67%, 36%, and 32% adolescents from these countries are thin.
In the study by Renuka Jayatissa et al., it was observed that the prevalence of overweight, thinness and stunting among the adolescent school girls in Sri Lanka were 4.0%, 22.1% and 18.1% respectively . In a study by Garba and Mbofung, the severe malnutrition was higher in girls (23.8%) than in boys (22.3%), while moderate malnutrition was higher in boys (93.1%) than in girls (86.7%) . Mital Prajapati et al. also found out that the prevalence of thinness was equal to 41.3% . The comparison of prevalence of undernutrition among the adolescents in India and other countries is presented in Table IV. Most of the studies reported lower prevalence of undernutrition than present study [28,29,30,33,36,38,45]. On the other hand, some other studies had almost similar prevalence of undernutrition [44,34,32], wheras some other studies showed a higher prevalence than present study [32,37].
Morbidity profile: The health problems of adolescent girls vary from place to place and several studies conducted in India and abroad revealed that the main morbidity conditions include malnutrition, dental caries, and diseases of skin, problem of Eye & Ear and reproductive problems.
In the present study, the leading causes of morbidity were undernutrition 56.4%, dental caries (27.1%), skin diseases (16%), dysmenorrhoea (16.7%), defective vision (4%), URTI (2.4%), ENT (2.1%) and clinical anaemia (pallor) 30%.
In a study conducted by Srinivasan  (2000), in Tirupati in 598 children aged 6-17 years, the common morbid conditions found were skin disorders 25.7%, dental caries 21.5%, ARI 1.7% and diarrohea 1.2%.
In the present study, the morbidity due to skin diseases is 16%. In the study by Srinivasan , scabies accounted for 29.9%. In a study by Singh et al.  scabies accounted for 16.2%.
In the present study, the prevalence of dental caries is found to be 27.1%. In the study by Srinivasan dental caries was 21.5%. 13.33% of dental caries was seen in the study conducted by Choudhary et al  in adolescent girls of rural area of Varanasi. The high prevalence of dental caries in the present study may be due to poor oral hygiene.
In the present study defective vision was 4%, whereas in other studies [10, 39] the prevalence of defective vision was 4.7% and 4.5% respectively. This difference may be due to inadequate indoor lighting.
In the present study dysmenorrhea is present in 16% of study subjects. In a study conducted by Deo et al.  dysmenorrhea was present in 31.64%. In a study conducted by Srinivasan dysmenorrhea was noted in 3.5%. The low prevalence of dysmenorrhea in the other studies may be due to the reason the study subjects comprised of different age groups. In a study by Geetha et al  in rural south India, dysmenorrhea was noted in 21%. Study by N Rema found that common deficiency diseases prevalent among the school going children were anemia and skin infections 10.6% & 67%. The chief cause of anemia could be contributed to the lack of proper iron, vitamin B12 and folic acid in the diets of these children .
The following are the conclusions from the present study:
A total 420 girls were studied. Of that 37.4% were in the age group 13 years. According to WHO reference standards 56.4% girls were under-nourished (BMI [less than or equal to] 18.5). Girls suffering from chronic energy deficiency grade I, II and III were 25.2 %, 15.2 % and 16 % respectively. Out of the total 420 girls, 12 (2.9%) was found to be overweight and none of the girls was found to be obese. According to the new guidelines by the government of India as per the diagnostic cut-off values the 56.4% was found to be undernourished while 5.8 % was found to be Overweight (BMI >23.5 kg/[m.sup.2]). However 30% were showed clinical anaemia, 27.1% were having dental caries, 16.7% were having reproductive problem (dysmenorrhoea), 16% were skin problem, 4 % Eye problem (defective vision & refractive error), 2.4% were having URTI, and 2.1% ENT problem. In view of the high prevalence and incidence of morbidity among adolescent girls in the hostels, regular periodic medical examination and facilities for treatment on the spot at school hostels and referral services should be organized and monitored systematically. Health education programmes on hygiene and common diseases have to be carried out regularly in hostels in consultation with concern health authorities.
Ethical Considerations: The study protocol was submitted to the Institutional Ethical Committee and clearance was obtained. Written informed consent from the heads of the institutions and assent from the selected adolescents was also obtained, before initiation of the study in the respective Institutions.
Conflict of Interest: There does not exist any conflict of interest what so ever.
Role of Funding Source: There does not exist any role of funding source what so ever.
The Principals and the authorities of both the Hostels are thankfully acknowledged for their help during data collection. Our thanks go to the professors & head of Department of Community Medicine, and the staff of Urban Health Centre for their continuous support.
Also our appreciation is extended to Respected Dean of MIMS Medical College and Management for giving us permission to carry out study. Also we are sincerely indebted to all the participants who made this study possible.
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Vinod Wasnik *, B. Sreenivas Rao, Devkinandan Rao
Department of Community Medicine, Maharaja Institute of Medical Sciences, Nellimarla, Vizianagaram District, Andhra Pradesh, India
* Corresponding Author
Table I: Details age wise distribution of study sample Age in Years Frequency Percent 10 10 2.4 11 21 5. 0 12 78 18.6 13 157 37.4 14 113 26.9 15 41 9. 8 Total 420 100.0 Table II: Nutritional Status of Study population as per National & International Classification of underweight, overweight and obesity according to BMI WHO standard * n = 420 BMI Cutoff No. of Grade of Undernutrition Value Kg/m2 Girls n (%) Grade 3 Thinness < 16 67 (16) Grade 2 Thinness 16.0-16.99 64(15.2) Grade 1 Thinness 17-18.49 106(25.2) Normal 18.5-24.99 171(40.7) Overweight 25-29.99 12(2.9) Obese >30 Nil Indian Standard ** Underweight < 18.5 237 (56.4) Normal 18.5-22.9 159( 37.8) Overweight 23 and Above 24( 5.8) * WHO The International Classification of underweight, overweight and obesity according to BMI.2004 ** Indian Council of Medical Research, 2009 Table III: Morbidity status of hostel Girls Morbidity Status Frequency Percent URTI 10 2.4 skin problems 67 16.0 Eye problems 17 4.0 ENT problems 9 2.1 Dental problems 114 27.1 Reproductive 70 16.7 NAD 7 1.7 Anaemia 126 30.0 Total 420 100.0 Table IV: Comparative Frequency of Thinness among the adolescent girls of different countries Reference Study Area Population Sex NurulAlam et al 2010 Bangladesh Girls Lazzeri G et al 2008 Tuscany,Italy Both Pascal Bovet et al June 2011 Seychelles Both (African Region) Afework Mulugeta et al, 2009 Ethiopia Girls Saxena Y et al 2011 Dehradun, India Girls Shivaramakrishna et al 2011 Banglore, India Girls X Du et al 2003 China Girls Yustina Anie Indriastuti Indonesia Girls Kurniawan et al 2006 Renuka Jayatissa et al 1997 Sri Lanka Girls A. K. M. Shahabuddin Bangladesh Both Bisai et al 2008 West Bengal, India Both CMG Garba et al 2010 Cameroon Both Mital Prajapati et al 2011 Gujarat India Both Vinod Wasnik 2011 (Present study) Girls Reference Study Date of Survey Undernutrition NurulAlam et al 2010 2003-2004 26% Lazzeri G et al 2008 2002-2006 17.9% Pascal Bovet et al June 2011 1998-2004 29.8% Afework Mulugeta et al, 2009 2004-2005 58.3% Saxena Y et al 2011 2010 56.25% Shivaramakrishna et al 2011 Jan-Feb 2009 73.5% X Du et al 2003 2001 32.2% Yustina Anie Indriastuti 2005 50% Kurniawan et al 2006 Renuka Jayatissa et al 1997 August to 22.1% December 1997 A. K. M. Shahabuddin December 1996 67% and January 1997 Bisai et al 2008 May 2008-March 09 44.5% CMG Garba et al 2010 -- 86.7% Mital Prajapati et al 2011 July 2008- 41.3% December 2008 Vinod Wasnik 2011 January 2010- 56.4% Augest 2010