clinicoepidemiological features


Original Article

CLINICO-EPIDEMIOLOGICAL FEATURES OF HYPERTENSIVE SUBJECTS IN KASSALA TOWN, EASTERN SUDAN

El Fadil M. Osman, FRCP,* Ikhlas Suleiman, MD, † Ahmed G. Alzubair, FRCP‡

*Department of Medicine, College of Medicine, University of Khartoum, and †Department of Medicine, Kassala University, Sudan, ‡Department of Family & Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

______________________________________________________________________________

هدف الدراسة: دراسة الخصائص السريرية و الوبائية لمرض ضغط الدم المرتفع فى قائمة من المصابين فى مدينة بشرق السودان.

طريقة الدراسة: شملت الدراسة 242 مصابا بمرض ضغط الدم المرتفع وذلك باستخدام إستبانة تحتوى على الخصائص السريرية و الوبائية المتعلقة بمرض ضغط الدم المرتفع.

نتائج الدراسة: كان ثلثا العينة من النساء بينما كانت أعمار  73.6% منهم بين 35 إلى 64 سنة. وكان ثلاثة أرباع العينة ممن نالوا تعليما أقل من المستوى المتوسط. و بينت الدراسة أن هنالك علاقة ذات أهمية إحصائية بين مرض ضغط الدم المرتفع في العينة و تاريخ المرض العائلي و كون المصاب من شمال السودان.

وبينت الدراسة وجود أكثرية ذات أهمية إحصائية من المصابين الذين عانوا من مرض الشرايين التاجية (ت أقل من 0.001) و كذلك أكثرية ذات أهمية إحصائية من المصابين من غرب السودان الذين أصيبوا بهبوط البطين الأيسر (ت أقل من 0.02) و كذلك هبوط القلب (ت أقل من 0.0001) ، بينما كانت هنالك أكثرية ذات أهمية إحصائية من جنوب السودان ممن أصيبوا باعتلال الكلى الناتج عن ضغط الدم المرتفع (0.007).

الخلاصة: أظهرت الدراسة بعض الخصائص السريرية و الوبائية في عينة من المصابين بمرض ضغط الدم المرتفع في شرق السودان. و أشارت إلى معدل منخفض للسيطرة على المرض مع احتمال وجود اختلافات في معدل السيطرة على المرض و مضاعفاته.

الكلمات المرجعية: مرض ضغط الدم المرتفع – الاختلافات الإثنية – مدينة كسلا

________________________________________________________________________

Objectives: To study the clinico- epidemiological profile of hypertension in a series of hypertensive patients in a town in Eastern  Sudan.

Methods: A sample of  242 hypertensive patients was studied using a structured questionnaire including the clinico-epidemiological features associated with hypertension.

Results: Two thirds of the sample were females, 73.6% of whom were in the 35-64 year age-range; three-quarters of them had a low level of education. Significant risk factors for hypertension included positive family history of hypertension, and being from the Northern Sudan. Significantly more patients from the eastern and western regions had coronary heart disease (P<0.001). Also, significantly more patients from Western Sudan had left ventricular failure (P<0.02) and congestive heart failure (p<0.0001), while significantly more patients from Southern Sudan had nephropathy (P<0.007).

Conclusions: The study reveals some clinico-epidemiological characteristics in a series of hypertensive patients in Eastern Sudan. It suggests a low rate of blood pressure control as well as ethnic variation of blood pressure control and complications.

Key Words:Hypertension, Ethnic variation, Kassala Town

_____________________________________________________________________________________________________________________


INTRODUCTION

Hypertension is a common problem. A recent estimate suggests that approximately one billion adults have hypertension (333 million in the developed and 639 million in developing countries) with the highest prevalence in Eastern Europe and the Latin America and the Caribbean.1

     


_____________________________________________________________________________________________________________________

Correspondence to:

Dr. El Fadil M. Osman, College of Medicine, University of Sudan P.O. Box 102, Khartoum, Sudan    E-mail:fmosman@hotmail.com


National surveys also indicate that both the average level of blood pressure and prevalence    of  hypertension  in  children  and  adolescents increased between 1988-2000.2 The disease, and its complications, is causing considerable morbidity and mortality. Furthermore, there are numerous management problems regarding early diagnosis, clinical assessment, and proper management.

      In Sub-Saharan Africa, hypertension is a common problem, especially in urban areas.3-6 Very few studies have been done in Sudan on this common problem. The people of Sudan are composed of a mix of African and Arabic ethnic groups. The Africans have their own languages, traditions, and belong to various religions, such as Islam, Christianity and others. On the other hand, those of Arabic ethnic background are Arabic speaking, and muslim. This differentiation may be a source of variation of the problem of hypertension as well as other chronic diseases. The ethnic groups in Sudan are distributed geographically, but the population of most towns in the country is made up of people from all over the country.

      The aim of this study is to describe some clinico-epidemiological aspects of the disease, in relation to ethnicity, in the form of geographical distribution of population using a series of outpatient clinic-based hypertensive patients, in Kassala town, in eastern Sudan.

METHODOLOGY

The study was carried out in Kassala teaching hospital, Kassala town, Eastern Sudan between 2003and 2004. A series of 242 hypertensive subjects was studied. The study's parameters were classified as blood pressure (BP) levels, risk factors for hypertension, and complications of hypertension. The variables related to those parameters were the geographical origin of subjects (classified as central, eastern, western, northern and southern), and as indicated by their tribal label, gender, age; and level of education (classified as low which included illiterate persons, as well as those who had no more than the intermediate level of education; average where subjects had high secondary school education, and high for those who had university degrees or more); family history of hypertension, body mass index (BMI), waste-hip ratio (W/H ratio) and presence of diabetes mellitus in the form of a diagnosis label with on-going treatment. The complications of hypertension were defined as the presence of coronary artery disease confirmed by electrocardiographic findings, left ventricular failure, congestive cardiac failure, stroke (which are all confirmed clinically, retinopathy (confirmed by ophthalmoscopic examination and defined as the presence of signs of hypertensive retinopathy,7 and nephropathy as confirmed by abnormal urea and creatinine levels and presence of albuminuria.

      Each patient was weighed and had his/ her height recorded to the nearest half kilogram and centimeter; respectively. The waist and hip circumferences were measured and recorded to the nearest one centimeter. The BMI was calculated as the weight in kilograms divided by the square of the height in meters. The W/H ratio was calculated as the waist circumference divided by the hip circumference.  A W/H ratio of more than one was considered as abnormal while a BMI of more than 25 kg/ht2 and a W/H ratio was considered as high. The BP was measured using a standard mercury sphygmomanometer with the patient in a sitting position, using a cuff of suitable size. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) were determined by first hearing of the Korsakoff's sound and their muffling; respectively. Blood pressure readings were classified as controlled or not controlled if the systolic  and diastolic blood pressure were equal to or more than 140 and 80 mm Hg, respectively.8

      Data were entered and analyzed using an IBM compatible computer incorporating the Statistical Package for Social Sciences (SPSS Version 11). Frequency distribution tables were generated. Chi-squared test was used to assess the significance between categories. A p-value of 0.05 or less was considered as indicative of statistical significance.

RESULTS

      Females formed two thirds of the sample of 242 subjects studied. Most patients (73.6%) were aged between 35 and 64 years, and almost three quarters of them had a low level of education. Subjects from the Northern and Western parts of the Sudan constituted about two-thirds of the sample (Table 1).

      The distribution of risk factors for hypertension revealed a significantly higher proportion of subjects, with a positive family history of hypertension, and origins from the northern region of Sudan (p<0.001). Of the remaining risk factors there were no statistically significant differences among the geographical regions (Table 2).

      Less than one-fifth of the sample had controlled blood pressure. There was significant variation between patients from different geographical areas of the country, the highest proportion of patients with controlled blood pressure were from Central Sudan (p<0.000) (Table 3).

      As regards complications of hypertension, significantly more subjects from the eastern and western regions had coronary artery disease (p<0.001). Also, significantly more subjects from the western region had left ventricular failure (p < 0.02) and congestive cardiac failure (p < 0.0001) than subjects from the other regions. Nephropathy was significantly more among subjects from the southern region (p<0.007) (Table 4).

Table 1: Demographic variables

Variable

No. (%)

Gender:

Males

  77 (31.8)

Females

165 (68.2)

Age distribution (years):

35

  31 (12.8)

35-64

178 (73.6)

65+

  33 (13.6)

Education level:

Low

188 (77.7)

Average

  30 (12.4)

High

24 (9.9)

Geographical origin:

Central Sudan

25 (10.3)

Eastern Sudan

31 (12.8)

Western Sudan

89 (36.8)

Northern Sudan

87 (36.0)

Southern Sudan

10 (4.1)


Table 2: Risk factors of hypertension according to geographical origin distribution

Risk factor

Geographical Distribution

Total

Eastern

Northern

Western

Central

Southern

Family history*

6 (19.4)

53 (60.9)

34 (38.2)

10 (40.0)

5 (50.0)

134 (100.0)

Diabetes mellitus

10 (32.3)

21 (24.1)

23 (25.8)

9 (36.0)

3 (33.3)

  66 (100.0)

High BMI

14 (45.2)

42 (48.3)

41 (46.1)

8 (32.0)

6 (60.0)

111 (100.0)

High WH ratio

10 (32.3)

39 (44.8)

30 (33.7)

5 (20.0)

4 (40.0)

  88 (100.0)

*p<0.001

Table 3: Blood pressure control according to geographical origin distribution

Geographical distribution

Controlled

Uncontrolled

Total

Eastern Sudan

  7 (22.6)

24 (77.4)

31 (100.0)

Northern Sudan

16 (18.4)

71 (81.6)

87 (100.0)

Western Sudan

  9 (10.1)

80 (89.9)

89 (100.0)

Central Sudan

12 (48.0)

13 (52.0)

25 (100.0)

Southern Sudan

  3 (30.0)

7 (70.0)

10 (100.0)

Total

47 (19.4)

195 (80.6)

242 (100.0)

Table 4: Complications of hypertension according to geographical origin distribution

Complication

Geographical Distribution

Total

Eastern

Northern

Western

Central

Southern

Coronary artery disease*

13 (41.9)

24 (27.6)

44 (49.4)

3 (12.0)

1 (10.0)

85 (35.1)

Left ventricular failure†

6 (19.4)

3 (3.4)

17 (19.1)

3 (12.0)

1 (10.0)

30 (12.4)

Congestive heart failure‡

0

3 (3.4)

18 (20.2)

    1 (4.0)

2 (20.0)

   24 (9.9)

Stroke

0

0

5 (5.6)

    1 (4.0)

0

6 (2.5)

Retinopathy§

3 (9.7)

12 (13.8)

  9 (10.1)

6 (24.0)

5 (50.0)

35 (14.5)

Nephropathy

8 (25.8)

23 (26.4)

21 (23.6)

3 (12.0)

5 (50.0)

60 (24.8)

*p<0.001, †p<0.02, ‡p<0.0001, §p<0.007


DISCUSSION

Since there are no symptoms in this condition, known as 'the silent killer', awareness of hypertension comes with an appropriate application of diagnostic criteria and a clear communication of the findings and relevant instructions by a member of the health care delivery team. The best means of increasing awareness of hypertension is an improvement in detection, and communication during routine clinical encounters. Effective mass screening programmes must be linked effectively to the settings of the health care provider where the diagnosis can be rapidly confirmed or refuted and treatment promptly initiated.

      Factors that influenced rates of awareness, treatment and control of hypertension include the extent to which individuals came in contact with the health care providers, the presence or absence of co-morbidities, the individual socioeconomic status, the integrity of social support network; and the extent to which the treatment and control of hypertension is a priority for the community; and the accessibility and affordability of health care.

      Hypertension is a major health problem worldwide and the Sudan is not an exception. In this study, hypertension was found with increasing age, female gender, and family history of hypertension, high body mass index and diabetes, a situation which is akin to findings from other communities.9-11 Moreover, the study revealed a less than 20% rate of controlled patients, which is low. This may be due to the lack of compliance with follow-up and medications as a result of a variety of well-known factors that are beyond the scope of this study.12-14 Urgent preventive measures need to be taken at the community level. These measures must focus on primary prevention, early tracking information, health education and suitable treatment, as well as management of any causes of non-compliance as was indicated in a previous study in the same area.15

      The study has also revealed some characteristics of variations in blood pressure dependent on ethnic origins. The Sudan is a country of multi-ethnic origins comprising more than 500 tribes, forming a mix of Afro-Arabian population. Variation in the clinical characteristics of hypertension, and in blood pressure control status, have been well documented,16,17 and this study highlights that in-depth studies of this should be carried out in the country.

CONCLUSION

This study revealed some clinico-epidemiological characteristics in hypertensive patients in Eastern Sudan. It also revealed a low rate of blood pressure control as well as suggestions of ethnic variations of those characteristics.

REFERENCES

1.        Kearney PM, Whellon M, Reynolds K, etal Global burden of hypertension. Lancet 2005:365(9455):217-23.

2.        Munter P,He J, CutlerJA, etal. Trends in blood pressure among children and adolescents in the United States. JAMA2004;291:2107-13.

3.        Kaufman JS, Barkey N. Hypertension in Africa: an overview of prevalence rates and causal risk factors. Ethnic Dis 1993;3(suppl):S83–101.

4.        Bunker CH, Ukoli FA, Nwankwo MU, Omene JA, Currier GW, Holifield-Kennedy L. Factors associated with hypertension in Nigerian civil servants. Prev Med 1992;21:710–722.

5.        Cooper R, Rotimi C, Ataman S, McGee D, Osotimehin B, Kadiri S, et al. The prevalence of hypertension in seven populations of West African origin. Am J Public Health 1997;87:160–8

6.        Akinkugbe OO. Editor. Non-communicable diseases in Nigeria: final report of a national survey. Lagos: Federal Ministry of Health and Social Services; 1997.

7.        Bert-Jan H van den Born, Caroline AA Hulsman, Joost BL Hoekstra, Reinier O Schlingemann, Gert A van Montfrans. Value of routine fundoscopy in patient with hypertension: systemic review. BMJ 2005;331(7508):73-7.

8.        Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LE, Izzo JL, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003;289: 2560-71

9.        Onal AE, Erbil S, Ozel S, Aciksari K, Tumerdem Y. The prevalence of and risk factors fro hypertension in adults living in Istanbul. Blood Press 2004;13(1):31-6.

10.     Olatunbosun ST, Kaufman JS, Cooper RS, Bella AF. Hypertension in a black population: prevalence and biosocial determinants of high blood pressure in a group of urban Nigerians. J Hum Hypertens 2000;14(4):249-57.

11.     Mazzaglia G, Mantovani LG, Sturkenboom MC, Fillipi A, Trifiro G, Cricelli C, Brignoli O, Caputi AP. Patterns of persistence with antihypertensive medications in newly diagnosed hypertensive patients in Italy: a retrospective cohort study in primary care. J Hypertens 2005;23(11):2093-100.

12.     Hassan NB, Hasanah CI, Foong K, Naing L, Awang R, Ismail SB, et al. Identification of psychological factors of noncompliance in hypertensive patients. J Hum Hypertens 2006;20(1):23-9.

13.     Baune BT, Aljeesh Y, Bender R. Factors of non-compliance with the therapeutic regimen among hypertensive men and women: a case-control study to investigate risk factors of stroke. Eur J Epidemiol 2005;20(5):411-9.

14.     Elzubier AG, Husain AA, Suleiman IA, Hamid ZA.  Drug compliance among hypertensive patients in Kassala town, Eastern Sudan. East Mediterr Health J 1999; 2000:6(1):100-5.

15.     Borrel LN. Self-reported hypertension and race among Hispanics in the National Health Interview Sudy. Ethn Dis 2006;16(1):71-7.

16.     Basker V, Kamalakannan D, Holland MR, Sing BM. Does ethnic origin have an independent impacton hypertension and diabetic complications? Diabetes Obes Metab 2006;8(2):214-9.

17.     Bosworth HB, Dudley T, Olsen MK, Vioils CI, Powers B, Goldstein MK, Oddone EZ. Racial differences in blood pressure control: potential explanatory factors. Am J Med 2006;119(1):70.e9 -15.



2007-12-04

The relationship of body weight


Original Article

THE RELATIONSHIP OF BODY WEIGHT TO ALTITUDE IN PRESCHOOL CHILDREN OF SOUTHWESTERN SAUDI ARABIA

Mohammad-Elhabeeb M. Khalid,MBBS,PhD(UK), Fahaid H. Al-Hashem,MBBS,PhD (UK)

Department of Physiology, College of Medicine, King Khalid University, Abha, Saudi Arabia

______________________________________________________________________________

هدف الدراسة: تحديد نسبة حدوث كل من السمنة والهزال وذلك في الأماكن ذات العلو الكبير عن سطح البحر ومقارنتها بالأماكن ذات الارتفاع القليل عن سطح البحر عند أطفال ما قبل مرحلة الدراسة في المنطقة الجنوبية الغربية من المملكة العربية السعودية.

طريقة الدراسة: تمت الدراسة بالشكل المقطعي المعروف على 559 طفلاً سعودياً تتراوح أعمارهم ما بين 12 – 71 شهر ممن ولدوا و عاشوا بشكل مستمر و دائم في منطقة ذات علو كبير عن سطح البحر و 463 طفلاً سعودياً من نفس الشريحة العمرية ممن ولدوا و عاشوا بشكل مستمر ودائم في ذات علو أقل عن سطح البحر. تم خلال الدراسة تسجيل العمر وحساب الطول والوزن لكل طفل كما تم تصنيف أوزان الأطفال إلى طبيعية, سمينة وهزيلة وذلك باستخدام معيار مناسب الوزن مع الطول حسب توصية منظمة الصحة العالمية.

نتائج الدراسة: كان كل من متوسط الوزن والطول أعلى و بشكل إحصائي مهم عند أطفال المناطق المرتفعة مقارنة مع نظائرهم أطفال المناطق قليلة الارتفاع. كانت نسبة الأطفال ذوي الأوزان الطبيعة 92.1% في الأماكن المرتفعة بينما كانت نسبتهم في الأماكن المنخفضة 67.6% (.(p < 0.0001 نسبة السمنة عالية ولكنها غير مهمة إحصائيا عند أطفال المناطق المرتفعة (2.3%) مقارنة بأطفال المناطق المنخفضة (0.9 %) ( .(p < 0.7 كانت نسبة الهزال مرتفعه ارتفاعاً ذا أهمية إحصائية عند أطفال المناطق القليلة الارتفاع (31.5%) مقارنة بأطفال المناطق العالية الارتفاع (5.5%) p<0.0001)). لا يوجد هناك فرو ق ذات دلالة إحصائية هامة في نسبة حدوث السمنة أوالهزال بين الذكور والإناث في كلا منطقتي الدراسة.   

الخلاصة: تدل نتائج هذه الدراسة أن الهزال يمثل مشكلة تغذوية كبيرة وذلك لدى أطفال المناطق القليلة الارتفاع وقد يعزى ذلك لكثرة نسبة حدوث الإنتانات المدارية عند أطفال المناطق قليلة الارتفاع عن مستوى سطح البحر.

الكلمات المرجعية: وزن الجسم، الأماكن المرتفعة، المملكة العربية السعودية.

____________________________________________________________________________________________________________Objectives: To determine the average weight and height and the prevalence of overweight or obesity and thinness in preschool children of  the Southwestern highlands of the Kingdom of Saudi Arabia and compare them with their counterparts living at lower altitudes.

Methods: A cross-sectional study of 559 preschool children aged 12-71 months born and living permanently at high altitude, and 463 preschool children of comparable age born and living permanently at low altitude. For each child at high and low altitude, age was recorded and weight and height were measured. Weight for height Z-score with WHO standards was used for an assessment of normal weight, overweight or obesity and thinness.

Results: The highland preschool children were found to be significantly heavier and taller than their counterparts living at low altitude. 92.1% of all highland preschool children and 67.6% of lowland preschool children were found to have normal weight (p < 0.0001). Overweight or obesity was insignificantly greater among preschool children of the highlands (2.3%) compared to the preschool children of the low lying areas (0.9%) (p<0.7). Thinness was significantly more prevalent among preschool children of the lowlands (31.5%) than preschool children of the highlands(5.5%) (p< 0.0001). At both high and low altitude, there were no significant differences in the prevalence of overweight or obesity and thinness between boys and girls.

Conclusion: The findings of this study indicate that thinness is a major nutritional problem among lowland preschool children. This may be attributed to the prevailing tropical environmental conditions on the health of children at low altitude.

Key Words: Body weight, Altitude, Saudi Arabia

_____________________________________________________________________________________________________________________

Correspondence to:

Dr. Fahaid H. Al-Hashem, Assistant Professor, Department of Physiology, College of Medicine, King Khalid University,                 P.O. Box 641, Abha, Saudi Arabia     E-mail: fahaid999@yahoo.com


INTRODUCTION

The composition of air stays the same but the total barometric pressure falls with increasing altitude. As a result, the partial pressure of oxygen falls and a state of hypoxia is said to occur.1 Certain biochemical, physiological and microanatomical responses occur during acclimatization and adaptation to chronic hypoxia of high altitude.2 Among these responses are changes in body build.2 Several studies on the relationship between high altitude and body build have been carried out in different parts of the world including the Andes,3 the Simen mountains4 and the Sarawat mountains.5, 6 However, to our knowledge no study on preschool children specific to the Southwestern highlands of Kingdom of Saudi Arabia has been reported. Furthermore, no attempts have been made to determine the prevalence of overweight or obesity in preschool children at high altitude.

      Many reports have shown that children's overweight or obesity is frequently associated with metabolic and psychological complications as well as hypertension.7 Of greater concern is the persistence of childhood obesity into adulthood along with its numerous associated health risks.7 On the other extreme, thinness poses an equally important health problem. In addition to its serious effects on physical health, it may also have adverse effects on child's cognitive and behavioral development.8 The present study was, therefore, undertaken to determine the average weight and height and the prevalence of overweight or obesity and thinness in preschool children of the Southwestern highlands of the Kingdom of Saudi Arabia and compare them with their counterparts living at low altitude.

METHOD

This study was carried out in high and low altitude areas of Aseer Province in the Southwestern part of the Kingdom of Saudi Arabia. Alsoda village and the villages around Sabit Allia city were selected at high altitude (2800-3150 m) and the villages around Mohyel city were selected at low altitude (500 m). Environmental data on these areas are shown in Table 1.9 Alsoda is approximately 600 km, and Sabit Allia approximately 520 km south of Jeddah (the second city in the Kingdom). Moyhel city lies in Tihama valley, approximately 550 km south of Jeddah. Health services for the two areas are provided by health centers run by qualified physicians who use two referral hospitals that are easily accessed by good roads. Potable water and electricity are available in these areas. Meat, chicken and rice constitute the major dietary items for people living in both areas.

Table 1: Environmental data on high and lowland of the study

Variables

Highland

Lowland

Altitude (meter)

2800-3150

500

Barometric pressure (mmHg)

550-590

720

Atomospheric O2 tension (mmHg)

110-120

145

Relative humidity (%)

20-30

50-90

Summer temperature (shade) (Co)

16-28

30-45

Winter temperature (shade) (Co)

5-15

25-35

      The data presented in this paper were obtained from 559 preschool children aged between 12-71 months, born and living permanently at high (about 89.2 % of the total preschool children registered in health centres at high altitude study area) and 463 preschool children of comparable age born and living permanently at low altitude (about 90.3% of all preschool children registered in the health centres at low altitude study area). Each child was first subjected to detailed clinical examination. Children in whom pathology was detected by clinical examination, as well as children who were not born and who did not live permanently in the designated study areas were excluded from this study. Of a total of 1046 children seen, 24 were excluded because they did not fulfill the criteria for inclusion in this study. All subjects were Arab and of Saudi nationality. All measurements were taken in the health centers. This study was carried out in 2002.

For each child, age in months was calculated and recorded from birth certificates at the time of examination. For children under two years, the body weight was measured on a baby scale and the supine length was taken with a measuring board (Harpenden). For children over two years, the body weight was measured with an Avery beam weighing scale and the standing height was measured with a stadiometer (SECA). The weights of the children in minimal clothing were taken to the nearest 0.1 kg, and the heights and supine lengths were taken without shoes to the nearest 0.5 cm.

Normal weight, overweight or obesity and thinness were assessed using the following WHO criteria:10


Table 2: Prevalence of thinness, normal weight and overweight or obesity among high altitude preschool Saudi children based on weight for height Z-score data by age and gender

Age group (months) /

Gender

Number

<-2 SD

Thinness

N (%)

+ 2 SD

Normal weight

N (%)

2 SD

Obesity

N (%)

Mean

Z-score

SD

Z-score

12-23

Male

36

2 (5.6)

34 (94.4)

0

-0.04

1.0

Female

36

2 (5.6)

34 (94.4)

0

-0.2

1.1

24-35

Male

55

5 (9.1)

49 (89.1)

1 (1.8)

-0.4

1.1

Female

49

0

47 (95.9)

2 (4.1)

-0.1

1.0

36-47

Male

59

1 (1.7)

57 (96.6)

1 (1.7)

-0.5

0.8

Female

47

4 (8.5)

41 (87.2)

2 (4.3)

-0.4

1.1

48-59

Male

68

5 (7.4)

61 (89.7)

2 (2.9)

-0.6

1.1

Female

83

4 (4.8)

77 (92.8)

2 (2.4)

-0.3

1.1

60-71

Male

65

6 (9.2)

57 (87.7)

2 (3.1)

-0.7

1.1

Female

61

2 (3.3)

58 (95.1)

1 (1.6)

-0.5

1.0

Total

Male

283

19 (6.7)

258 (91.2)

6 (2.1)

-0.5

1.0

Female

276

12 (4.3)

257 (93.1)

7 (2.5)

-0.3

1.1

Table 3: Prevalence of thinness, normal weight and overweight or obesity among low altitude preschool Saudi children based on weight for height Z-score data by age and gender

Age group (months) /

Gender

Number

<-2 SD

Thinness

N (%)

+ 2 SD

Normal weight

N (%)

2 SD

Obesity

N (%)

Mean

Z-score

SD

Z-score

12-23

Male

32

12 (37.5)

20 (62.5)

0

-1.5

1.0

Female

32

8 (25.0)

24 (75.0)

0

-1.2

1.1

24-35

Male

47

23 (48.9)

24 (51.1)

0

-1.9

1.0

Female

40

10 (25.0)

29 (72.5)

1 (2.5)

-1.3

1.1

36-47

Male

59

26 (44.1)

33 (55.9)

0

-1.8

0.9

Female

35

9 (25.7)

26 (74.3)

0

-1.5

0.8

48-59

Male

48

13 (27.1)

34 (70.8)

1 (2.1)

-1.5

1.2

Female

49

18 (36.7)

31 (63.3)

0

-1.6

1.0

60-71

Male

62

14 (22.6)

46 (74.2)

2 (3.2)

-1.3

1.2

Female

59

13 (22.0)

46 (78.0)

0

-1.3

0.9

Total

Male

248

88 (35.5)

157 (63.3)

3 (1.2)

-1.6

1.1

Female

215

58 (27.0)

156 (72.6)

1 (0.5)

-1.4

1.0


Normal weight: proportion of preschool children between -2 standard deviation (SD) and +2 SD from the median weight for height of the National

Center for Health Statistics and the Centers for Disease Control and prevention (NCHS/CDC).

Overweight or obese: proportion of preschool children above +2 SD from the median weight for height of the NCHS/CDC reference population. Thinness: proportion of preschool children below -2 SD from the median weight for height of the NCHS/CDC reference population.

      At different stages of the study, the collected data were compiled and fed into a computer. SPSS package version 10 was used for statistical

analysis. Student T-test, Chi-square test and Crude odd ratios (cOR) with 95% confidence interval (CI) were used where appropriate to determine statistical significance. P value < 0.05 was considered statistically significant.

RESULTS

The total number of preschool children recruited for this study at high and low altitudes was 559 and 463 respectively, giving response rates of 89.2% and 90.3%. The boys to girls ratio at high altitude was nearly 1:1 while that at low altitude was 1.3:1. The mean ages ± standard deviations (SDs) in months of boys and girls at high altitude were 42.3 ± 15.5 and 43.4 ± 15.4 respectively (p<0.4). The respective values in the sample from low altitude were 44.6 ± 16.6 and 44.4 ± 17.1 (p<0.9). There were no significant differences in the mean ages between boys and girls at high altitude and their peers at low altitude (p<0.1 for boys and 0.5 for girls).

      The highland preschool children were found to be significantly heavier and taller than their counterparts living at low altitude. This was true for both boys and girls. The average height and weight of the highland boys were 96.1 ± 12.6 cm and 14.4 ± 3.4 Kg respectively while the average height and weight of the lowland boys were 91.9 ± 11.9 cm and 11.9 ± 3.0 kg respectively (p<0.0001 for both height and weight). At high altitude the average height and weight of the girls were 95.0 ± 11.9 cm and 13.9 ± 3.2 kg respectively compared with an average height of 91.0 ± 12.6 cm, and average weight of 11.6 ± 2.7 kg in lowland girls (p<0.0001 for height and weight).

      Weight for height Z-score was used for the assessment of normal weight, overweight or obesity and thinness in the two localities. Ninety two percent of all highland preschool children and 67.6% of all lowland preschool children were found to have normal weight (cOR 5.6, 95% CI [3.9-8.1], p<0.0001). Table 2 and 3 show the prevalence of normal weight, overweight or obese and thinness by age and gender. Although the overall prevalence of overweight or obese was greater among highland children (2.3%) compared to lowland children (0.9%) the differences was not statistically significant (p<0.7). At both high and low altitude, there were no significant differences in the prevalence of overweight or obesity between boys and girls (p<0.8 for highland children and p<0.6 for lowland children). Similar trends were observed when the same sexes were compared at different altitudes (p<0.6 for boys and p<0.2 for girls).

      Thinness was significantly more prevalent among lowland children (31.5%) than their counterparts living at highland (5.5%) (cOR 7.8, 95% CI [5.2-11.8], p<0.0001). This was true for both boys (cOR 7.6, 95% CI [4.5-13.1], p<0.0001) and girls (COR 8.1, 95% CI [4.2-15.6], p<0.0001). At both high and low altitude, thinness was more prevalent among boys than girls although the differences were not statistically significant (p<0.3 for highland children and p<0.06 for lowland children).

DISCUSSION

The results presented in this paper have shown that preschool children of the southwestern highlands of the Kingdom of Saudi Arabia are significantly taller and heavier than their counterparts of comparable age living in the low lying areas. It also showed that thinness was significantly more prevalent among lowland preschool children than preschool children living at high altitude while no significant difference in the prevalence of overweight or obesity was observed between the two groups of preschool children.

      In this study, age was calculated in months from birth certificates, and weight and height were carefully measured and recorded using equipment of well-tested design, and calibrated at frequent intervals. The observed SDs of weight for height Z-score at both high and low altitude were, therefore, relatively constant (Tables 2 and 3) and fell within the expected range recommended by the WHO (0.85-1.1).10

      As such, our results are contrary to the findings of the studies done in the Andes and Himalayas,3 but consistent with findings from the Simen mountains of Ethiopia.4 In the Andes and Himalayas, the differences in weight and height between highland and lowland children was attributed to the growth retarding effect of high altitude hypoxia as well as racial, dietary and socioeconomic factors of parents.3 In Ethiopia, the difference was related to high prevalence of intestinal parasitism in lowland children.4 In this study, we have attempted to reduce the contribution of racial and dietary factors by drawing our subjects from Saudi Arabswho not only had the same ethnic background but also the same dietary habits. Thus, the factor that appeared to be at work in our situation was purely environmental. Children born at high altitude had a lower birth weight when compared with their counterparts born at low altitude. This has been documented in a number of studies in this region11-13 and worldwide.14,15 The difference in birth weight was attributed to the intrauterine hypoxia to which the fetus is subjected. The intrauterine hypoxia appeared to be secondary to maternal hypoxia resulting from high altitude hypoxia.11,12 Infants with low birth weight have a greater proportion of fat relative to lean body mass.16 Therefore, in effect they are obese if obesity is to be defined as excess of body fat. In addition, infants with low birth weight have an increased risk of developing overweight or obesity later in childhood especially if they are not breast fed exclusively.17 All these may explain the higher prevalence of overweight or obesity, although insignificant, among highland preschool children as compared to their counterparts at low altitude. However, as children grew older, those living at high altitude appeared to have an advantage over lowlanders. Because of the tropical nature of the studied area, the lowland children were exposed to more tropical infections. On the other hand, highland children were exposed to cold weather which is beneficial in reducing tropical infections. In this context, malaria was found to be prevalent in Tihama valley, whereas the Southwestern highlands of the Kingdom are free from malaria.18, 19 The prevalence of other tropical infections such as leishmaniasis is also greater among people of the lowlands than those in the highlands.20 It is also worth mentioning that in this particular population of children, the prevalence of pathological intestinal parasites was significantly higher among lowland children (10.4%) than highland children (5.5%) (p<0.003). Malaria21,22 and intestinal parasitism4 are believed to be major causes of thinness in children. It is most likely, therefore, that the difference in the prevalence of thinness between high and lowland preschool children was related to the beneficial effects of the prevailing milder environmental conditions on the health of children at high altitude. However, this does not exclude other factors such as socioeconomic conditions of parents, which by implication are relatively unimportant.

      Although, thinness is often associated with malnutrition, clinical examination of thin subjects at high and lowland did not reveal any feature related to malnutrition. However, since biochemical tests were not done in this study, it was not possible to exclude subclinical forms of malnutrition. In addition, the NCH reference used in this study is limited by biological and technical drawbacks. An important limitation is the fact that the distribution of weight for height was markedly skewed towards the higher end reflecting substantial rate of childhood obesity. The use of NCH reference is, therefore, likely to have underestimated the rates of overweight or obesity and overestimated the rates of thinness. This shows that anthropometric studies among Saudi children are required to enable valid growth charts to be drawn.

      In conclusion, based on WHO criteria, the present study has given a clear indication that thinness is a major nutritional problem among preschool children of low lying areas while there is no such problem at high altitude. There was a lower prevalence of overweight and obesity in preschool children of both high and lowlands than what has been reported in other developing countries23 (3.3%). Our finding in this respect calls for further large scale studies to confirm these results. Such large scale studies will help in the planning and delivery of health care in this region.

ACKNOWLEDGMENT

The authors would like to thank all the medical and administrative staff working in the health centers who were involved in this study during the field work.

REFERENCES

1.        Ganong WF. Review of Medical Physiology, 17th Edition. Lange Medical Publications 1995; 591-607.

2.        Ward PW, Millege JS, West JB. Altitude and haemoglobin concentration. In: Ward PW, Millege JS and West JB, eds. High altitude Medicine and Physiology. London: Chapman and Hall, 1989; 170-1.

3.        Frisancho AR. Human growth and development among high population. In: the biology of high altitude peoples. Backer PT.Ed. Cambridge University Press Cambridge 1978; 117-71.

4.        Clegg EJ, Pawson IG, Ashton EH, Flinn RM. The growth of children at different altitudes in Ethiopia. Philosophical transaction of the royal society of London 1972; series B, Bio Sci; 264: 403-37.

5.        Al-Hashem FH. Pattern of haemoglobin among high and low altitude children of southwestern Saudi Arabia. J Family Commun Med 2006; 13: 35-40.

6.        Khalid MEM, Ali ME. Relationship of body weight to altitude in Saudi Arabia. Ann Saudi Med 1994;14:300-3.

7.        Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev 2004; 5: 4-85.

8.        Mendez MA, Adair LS. Severity and timing of stunting in the first two years of life affect performance on cognitive tests in late childhood. J Nutr 1999; 129: 1555-62.

9.        In: Climate Atlas of Saudi Arabia.  Riyadh, Saudi Arabia: Ministry of Agriculture and Water, 1988.

10.     World Health Organization Expert Committee. Physical status, the use and interpretation of anthropometry. World Health Organization: Geneva, 1995.

11.     Ali ME, Khalid MEM. The effect of high altitude on birth weight in the Asir Region, Saudi Arabia. Saudi Med J 1996; 17: 32-5.

12.     Khalid MEM, Ali ME, Ali KZM. Full term birth weight and placental morphology at high and low altitude. Int J Gyn Obst 1997; 50: 20-6.

13.     Al-Shehri MA, Abolfotouh M A, Dalak MA, Nwoye LD. Birth anthropometric parameters in high and low altitude areas of Southwest Saudi Arabia. Saudi Med J 2005;26:560-5.

14.     Oski FA, Naiman JLE. Hematologic problems in the newborn. Philadelphia: W.B. Saunders, 1982.

15.     Ballew C, Hass JD. Hematological evidence of fetal hypoxia among newborn infants at high altitude in Bolivia. Am J Obstet Gynecol 1986;155:166-9.

16.     Hediger ML, Overpeck MD, Maurer KR, Kuczmarski RJ, Mcglynn A, Davis WW. Growth of infants and young children born small or large for gestational age: findings from the Third National Health and Nutrition Examination Survey. Arch Paed Adolesc Med 1998;152:1225-31.

17.     Lederman SA, Akabas SR, Moore BJ. Editors overview of the conference on preventing childhood obesity. Paed 2004;114: 1139-45.

18.     Annobil SH, Okiahilam TC, Jamjoom GA, Bassuni WA.  Malaria in children – Experience from Asir Region.  Ann Saudi Med 1994;14: 467-70.

19.     Malik GM, Seidi O, El-Taher A, Mohammed A. Clinical aspects of malaria in the Asir region, Saudi Arabia. Ann Saudi Med 1998;18:15-7. 

20.     Buttiker W, Al-Ayed IH, Al-Wabil AH, Assalhy HS, Rashed AM, Shareffi OM.  Medical and Applied Zoology in Saudi Arabia. A preliminary study on leishmaniasis in two areas of Asir region. In: Fauna of Saudi Arabia vol 4, Wiltmer W and Buttiker W, eds. Jeddah: Meteorology and Environmental protection Agency, 1982;509-19.

21.     McGregor IA. Malaria and Nutrition. In: Malaria principles and practice of malariology 1988. Churchil Livingstone, London, pp 753-68.

22.     Shankar A. Nutritional modulation of malaria morbidity and mortality. J infect Diseas 2000; 182 (supppl 1): 37-53.

23.     de Onis M, Blossner M. Prevalence and trends of overweight among preschool children in developing countries. Am J Clin. Nutr 2000;72:1032-9.



2007-12-04

Level and determinants of infant


Original Article

LEVEL AND DETERMINANTS OF INFANT AND UNDER-FIVE MORTALITY IN WAD-MEDANI  TOWN, SUDAN

Huda M. Haroun, MPCH,* Mohmamed S. Mahfouz ,PhD, Khalid H. Ibrahim, MSc

Departments of *Pediatrics, Applied Statistics and Demography, and Population and Development, University of Gezira, Wad-Medani, Sudan.

______________________________________________________________________

هدف الدراسة: تهدف هذه الدراسة لتحديد مستوي وفيات الرضع والأطفال اقل من عمر 5 سنوات وتحديد تأثير العوامل الاقتصادية والاجتماعية الديمغرافية والبيئية علي صحة الطفل .

طريقة الدراسة: تم جمع المعلومات عن طريق الاستبانه لنساء ودمدني أنتجت 300 عينه في الفئة العمريه من 15- 49 سنه حيث تم تحليل البيانات إحصائيا

نتائج الدراسة: وجد أن معدل وفيات الرضع بمدينة ودمدني بالسودان 77 لكل إلف طفل حي ومعدل وفيات الأطفال 67 لكل إلف طفل حي كما وجد أن هناك علاقة احصايئه دالة بين وفيات الرضع والأطفال ومستوي التحصين، الترتيب الولادي, وزن الطفل عند الولادة واستخدام وسائل تنظيم الأسرة وتعليم الأمهات.

التوصيات: نوصي الدراسة باهتمام الدولة بخدمات التحصين والتثقيف الصحي  وتعليم الأمهات .

الكلمات المرجعية: محددات، الرضع، أطفال أقل من 5 سنوات، السودان.

____________________________________________________________________________________________________________

Aim: This study aimed to determine the level of infant and under-five mortality rates and to examine the effect of socioeconomic, demographic and environmental factors on the health status of the children under five years.

Methods: The data for this study were collected by means of a questionnaire addressed to women in Wad-Medani, Sudan. Three hundred women in the reproductive age (15-49) years were chosen randomly for this study. The data were analyzed statistically using the Statistical Package for Social Sciences (SPSS). Frequency distributions and a statistical test based on Chi-square for independence was conducted.

Results: Infant mortality rate was 77 per 100 and child mortality rate was 67 per 100. The results revealed that immunization, child order, child birth weight, birth interval and contraceptive use had a significant influence on the mortality of children under the age of five. The mother's level of education is highly significant on the mortality of children under five years old.

Conclusions: The Ministry of Health should give greater attention to improving immunization services and concentrate on health education campaigns for mothers and for the community.

Key Words:  Determinants, Infant, Underfive mortality, Sudan.

______________________________________________________________________________


INTRODUCTION

Infant and child mortality rates are regarded as indicators of the prevailing health conditions in a society; they measure the success of health programmes and policies aimed at their education.

      The World Summit for Children, held in 1990, instituted a package of objectives for implementation by the year 2000. Among these objectives was the aim to reduce infant and under-five mortality by one third or to 50 and 70 deaths per 1000 births, respectively, whichever was less.1 This was reaffirmed at the 1994 International Conference on Population and Development (ICPD).2 The 1992 population policy of Sudan announced the intention to reduce the mortality rates of children under five years of age to 60 deaths per 1000, from the level in 1992 by the year 2002.3

      Sudan is a developing country characterized by high levels of infant and child mortality. According to the 1993 fourth national population census, under-five mortality rate was 150 per


__________________________________________________________________________________

Correspondence to:

Dr. Huda M. Haroun, Head, Department of Pediatrics, Faculty of Medicine, University of Gezira, P.O. Box 20, Wad-Medani, Sudan 

E-mail: huda_haroun@yahoo.com


1000 live births and one out of ten infants        died before reaching their first birth day. The Safe

Mother Survey (SMS) which was conducted in 1999 showed that under-five mortality rate was 105 per 1000 live births and infant mortality rate was 69 per 1000 live births.4

      The persistence of high infant and child mortality rates, call for the identification of the main causes of this phenomenon. Moreover, there is a dearth of community studies on infant and child mortality.

      The main objectives of this study were to determine the level of infant and child mortality rates in Wad-Medani and to identify the main causes.

METHODS

Study area and Population

Wad-Medani is the capital of the Gezira State. It is the second largest town in Sudan and lies on the bank of the Blue Nile. According to the  fourth national census,  Wad-Medani has a population of 430,487 comprising 214,670 males and 215,817 females.5 Its population is a mixture of different tribal groups of Sudan, most of whom are government employees, traders, farmers, and casual laborers. The average health situation in Wad-Medani town is better than the national average and also better than any of the other towns in Sudan.6

      The data of this study came from a household survey conducted in September 2004. A simple random sampling technique was used with anticipated population proportion estimated to yield 300 women who had at least one child under five years of age.  A sample of 504 children under-five in 300 household were investigated using a questionnaire. This questionnaire consisted of two sets of data; the first set asked for the child's sex, birth weight, birth order, birth interval, immunization and child mortality, while the second set dealt with the mother's socio-economic status and other environmental variables.

      After the data were collected and coded, the Statistical Packet for Social Sciences (SPSS) were used to analyze the data. General tabulations including frequency distribution were used. Also chi-square test was used to evaluate some associations between the dependent variable infant and child mortality and a set of independent variables.

RESULTS

Demographic  and Bio-medical Characteristics of the Children

Table 1 shows that 20.6% of the children were below the age of one and 79.6% of them were between 1 and 5 years. The sex percentages of infants and children under five was 43.7% males and 56.3% females. The birth weight of the children was classified into three groups: under weight, normal weight and unknown weight. Those underweight were 26.2%, children with normal birth weight accounted for 62.7% and unknown birth weight were 11.1%.

Table 1: Demographic and Biomedical Characteristics of the Children

Characteristics

No. (%)

Age groups

Less than one year

104 (20.6)

Between one year and <5 years

400 (79.4)

Distribution of Children by sex

Male

220 (43.7)

Female

284 (56.3)

Distribution of children by weight

Under weight

132 (26.2)

Normal weight

316 (62.7)

Unknown weight

56 (11.1)

Child immunization

Full

328 (65.1)

Partial

140 (27.8)

None

36 (7.1)

Birth order

1

24 (4.8)

2.3

112 (22.2)

4-5

162 (32.1)

6 and above

206 (40.9)

Birth interval

< one year

168 (33.3)

1-2 years

232 (46.1)

More than 2 years

104 (20.6)

Total

504 (100)

      On the immunization status of the children, 65.1% of the children had been fully vaccinated, 27.8% partially immunized, while only 7.1% had no immunizations. The distribution of children by birth order is shown in Table 1. As can be seen from the table, 40.9% of the children were in the group ( six and more) births, 32.1% in the group (four to five) births, 22.2% in the group (two- three) births and only 4.8% in the first group (first child). For 33.3% of the children, the birth interval was less than one year,  for 46.1% it was 1-2 years and it was more than two years for 20.6%.

Mother’s Educational, Occupational and Marital Status

Table 2 shows mother’s education, occupation and marital status.  The percentage of women with 4-8 years of education was 11.7%, 9-12 years was 58.7%, 13-16 years was 29% and 0.6 formed the last category with more than 16 years of education. The same table shows that 91% of the women were housewives, 7% were employed,1%   had other occupations.  It was found that 98.6% were married, 0.7% were widowed and 0.7% were divorced. Of the mothers, 96.3% used contraceptive measures, while 3.7% did not.

Table 2: Mother's educational, occupational and marital status

Characteristics

No. (%)

Education

4-9 years

  35 (11.7)

9-12 years

176 (58.7)

13-16 years

87 (29.0)

16

2 (0.6)

Occupation

Employer

21 (7.0)

Worker

  3 (1.0)

Housewife

273 (91.0)

Others

  3 (1.0)

Marital status

Married

296 (98.6)

Widowed

  2 (0.7)

Divorced

  2 (0.7)

Contraceptive use

Yes

289 (96.3)

No

11 (3.7

Total

300 (100)

Table 3: Family income and some selected community and environmental variables

Characteristics

No. (%)

Average expenditure per day

Low

90 (30.0)

Medium

282 (60.7)

High

28 (9.3)

House type

Bricks

292 (93.3)

Jalose (traditional)

  8 (2.7)

No. of rooms per house

One

  46 (15.3)

Two

109 (36.3)

Three

94 (31.3)

Four

51 (17.3)

Latrines

Siphon

110 (36.7)

Pit latrine

190 (63.3)

Keeping animals

Inside

45 (60.0)

Outside

30 (40.0)

Total

300 (100)

Family Income and some Selected Community and Environmental Variables

Table 3 shows the distribution of the sample households by the level of expenditure. It is obvious from the table that the majority of families (60.7%) belonged to the middle income group, whereas the low and high income groups formed 30.0% and 9.3% respectively.

      Housing conditions and sanitation are known to be important determinants of the level of infant and child mortality. Table 3 shows   the types of houses, and number of the rooms and latrines. Ninety-seven point 3 percent of the women reported that their houses were made of bricks, 36.3% reported their houses had two rooms, 31.3% three rooms, and 17.1% had four rooms while 15.3% had one room only. When asked about latrines, 63.3% of the same women said they had pit-latrines, while only 36.7% had siphon. Seventy-five families kept animals, 60% of whom said the animals were kept inside the house, while 40% kept them outside.

Infant and Under-Five Mortality

Table 4 shows child deaths. It was found that 7.7% of the women's infants had died, while 92.3% of them are alive. This meant that infant mortality rate was 77 deaths per 1000 live births. For the age group 1-5 years, 6.7% of the children had died, while 93.3% of them were alive, yielding Child Mortality Rate  for that age group as 67 per 1000 live births.

Table 4: Infant and child mortality

Mortality

No. (%)

Infant mortality

Yes

8 (7.7)

No

96 (92.3)

Child mortality (1-5 years)

Yes

34 (6.7)

No

470 (93.3)

Associations  Between the Mortality of Infants and Children Under five and Some Selected Variables

In this part, cross-tabulation for the most important variables relating to infant and under-five mortality are presented. In each case, a test of independence was performed using χ2    (Chi -square) test of independence. The independent variables that were assumed to affect the mortality of infants and children under five significantly (dependent variable) were child order, child interval, child weight, child immunization, mothers' education, family income, keeping of animals, latrines and the use of contraceptives.

      Table 5 shows that child order, child weight, interval between children, child immunization, the use of contraceptives, family income, mother's education and latrines were all significant at 1%, while only the keeping of animals was significant at 5%.  This means that all these variables were strongly associated with the mortality of children under five years old and increased the risk of infant and child mortality.

Table 5: Association between children under-five mortality and some selected variables

No.

Independent variable

X2 value

Significance

1

Child order

127.0

0.000*

2

Child interval

47.59

0.009*

3

Child birth weight

51.12

0.001*

4

Child immunization

40.05

0.003*

5

Mother's education

25.68

0.001*

6

Keeping animals

6.03

0.049†

7

Latrines

32.90

0.003*

8

Contraceptive use

22.13

0.000*

*significant at 1% and †significant at 5%

DISCUSSION

Since the 1970s, the estimated annual number of deaths among children of less than 5 years has decreased by almost a third. This reduction has been very uneven and in some countries the rates of childhood mortality are increasing. In 1998, more than 50 countries including Sudan still had childhood mortality rates of over 100 per 1000 live births.7

      According to Rutstein (1984), Infant Mortality Rate (IMR) is the number of infants dying in the first year of life per 1000 live birth, whereas child mortality rate (1-5) is the probability of dying between the first and fifth birthday expressed per 1000.8

      The analysis of infant and child mortality in Wad-Medani reveals that infant mortality rate is 77 per 1000 live births. This figure is consistent with the findings of the 1999 Safe Mother Survey (SMS),7 in which the national level of infant mortality was estimated at 68 deaths per 1000 live births. Also the  study estimated under-five mortality as 67 deaths per 1000 live births. The  Multiple Indicators Cluster Survey (MICS) which was conducted in the Gezira State in 2002, showed an analogous level in which 59 out of 1000 children died before reaching the age of five.9

      On examination of the determinants of infant and child mortality, the study found a strong association with child order.  As parity increases, the risk of infant and child mortality increase. Many studies suggest that infant and child mortality increase with the increase of parity after the second birth. The higher the parity, the shorter the birth interval, and the shorter the birth interval the higher risk of dying for a child. The risk of dying is considerably higher for a  child who has a sibling born within the preceding two years.10,11 On the other hand, other studies suggest that infant and child mortality is generally higher for first born children, especially during the first year of life.12

      The study showed that there is a significant association between birth interval and infant and under-five mortality. The length of the birth interval is a very important factor for the survival status of infants and children. If the length of the birth interval is short, the probability of dying is high. The probability of dying before age five for children born less than two years after a previous birth is more than double that for children born four or more years after a previous birth.13 Moreover, short birth intervals have indirect effects through such factors as mother's depletion, premature birth and limited family resources.11

      The birth weight of the child has been found to be statistically significant as a determinant of under-five mortality.  In line with results found elsewhere, mortality decreased with the child's increase in weight at birth. The rates of mortality for children who were under weight at birth were higher than those who had normal weight at birth.14       

      Further, the study showed a significant association between mother’s education and infant and under-five mortality.  Maternal education has been identified as one of the most important socioeconomic determinants of infant and child mortality. Many studies show that the higher the level of maternal education, the lower the infant and child mortality.15 Caldwell (1981) provided three explanations for the phenomenon: better educated mothers become less fatalistic about their children's illnesses. They are more capable of manipulating available health facilities and personnel and they greatly change the traditional balance of familial relationships with a profound effect on child care. In addition to these, they are more likely to have had antenatal care, to have given birth with some medical attention, and to have taken their children at some point to see a physician.16.

      Regarding the significant association between the use of contraception and child mortality, we found that 73% of the women had not used any contraceptive methods within the last twelve months because of lack or unavailability in many of the areas covered by the study.

      Immunization was an important factor affecting under-five mortality. The study showed a significant association between immunization and child mortality. However, not all the children had been vaccinated (full immunization 65.1%), because of the fear of complications from immunization.

      Lack of latrines leads to high environmental contamination in houses and makes children more vulnerable to infectious diseases. Poor toilet facilities tend to increase infant and child mortality. For example, in an inter-American study, the incidence of diarrheal disease was lowest in households with pipe-borne drinking water and flush toilet facilities. Current access to proper toilet facilities was found to influence infant mortality, especially beyond the post-neonatal stage.12 Considering the association between the keeping of animals and child mortality, it was found that most households  kept animals inside their  houses, which increased the hazards of infectious diseases.  

CONCLUSION AND RECOMMENDATIONS

The conclusion of this study is that infant and under-five mortality in Gezira State was still high and socioeconomic and environmental factors had a lot of influence on the health status of children in Wad Medani.

      Finally, this study recommends   the expansion of immunization of children, and education for mothers in order to promote family planning and improve child health.Alsofurther detailed research is needed to provide better explanations for the determinants of the higher rates of infant and child mortality in Sudan.

REFERENCES

1.     Ariunaa Dashtseren. Determinants of Infant and child Mortality in Mangolia, IUSSP Regional Conference, Bangkong, Thailand, 9-13 June 2002.

2.     United Nation. Programme of Action of the 1994 International Cosnference on Population and Development. New York: United Nation Publication, 1999,

3.     Government of Sudan. Population Policy of Sudan. Population Council Khartoum, Sudan 1996.

4.     Central Bureau of Statistics. Safe Motherhood Survey (1999), National Report, Khartoum 2001.

5.     Central Bureau of Statistics. The Fourth Population Census, 1993, Principal Report, Khartoum 1995.

6.     Central Bureau of Statistics. Sudan in Figures, Ministry of Finance and Economy, Khartoum 2000.

7.     World Health Organization. World health report 1999: Making diffrence, Geneva: WHO 1999.

8.     Rustein, Shea O. Infant and Child Mortality: Levels, trends and demographic differentials. World Fertility Survey comparative studies, No. 43, Voorburg, Netherlands: International Statistical Institute, 1984.

9.     Central Bureau of Statistics. Multiple Indicators Cluster Survey (MICS), Medani, Khartoum: Ministry of Finance and Economy 2002.

10.   Hobcraft JN, McDonald, JW, Rutstein SO. Socioeconomic factors in infant and child mortality: A cross-national comparison, World Fertility Survey, London 1982.

11.   Hobcraft JN, McDonald JW, Rutstein SO. Demographic determinants of infant and early child mortality: Comparative analysis. Population studies 1985: 39.363-85.

12.   Hobcraft JN, McDonald JW, Rutstein SO. Child spacing effects on infant and child mortality. Population Index 1983;49:585-618.

13.   National Office of Statistics and UNFPA (1999). The Reproductive Health Survey of Mongolia, 1998.

14.   Mosley WH, Chen LC. An analytical frame-work for the study of child survival in developing countries. Population and Development Review 1984; (10 suppl.) 25-45.

15.   Caldwell JC. Maternal education as a factor in child mortality’, World Health Forum 1981; 2: 75-8.

16.   Murray CJL. Lopez AD. The global burden of disease a comprehensive assessment of mortality and disability from diseases, injuries and risk factors 19990; project to 2020, Geneva, WHO 1996.



2007-12-04