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Principal Investigator & Scientist ‘B’ & Dr. Tapas Chakma Co-Investigator & Scientist –‘G’ Head of NCD-Division
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ICMR-National Institute of Research in Tribal Health (Indian Council of Medical Research) i | P a g e Jabalpur (Madhya Pradesh)
Project Report On "HEALTH ASSESSMENT OF VILLAGERS OF TAMNAR BLOCK, DISTRICT RAIGARH (C.G.)”
Submitted By
Dr. Suyesh Shrivastava MBBS, MD (COMMUNITY MEDICINE) Principal Investigator & Scientist ‘B’ Mob- +919200265496, Phone- 0761-2370800 Email: [email protected] & Dr. Tapas Chakma MBBS, MAE, Co- Principal Investigator & Scientist ‘G’ Head, Division of Noncommunicable Disease (NCD) Email: [email protected]
Project Coordinator Dr. Aparup Das Director and Scientist-G ICMR-NIRTH, Jabalpur, M.P.
Submitted To Indian Council of Medical Research, New Delhi
Year 2019-2020
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Team Members
Principal Dr. Suyesh Shrivastava, MBBS, MD, Scientist ‘B’ Investigator Co- Principal Dr. Tapas Chakma, MBBS, MAE, Scientist ‘G’ Investigator Mr. Arvind Kavishwar, M.Sc, PGDCSA (Pr. Techn.Officer) Mr. Ashok Kumar Gupta, B.A., DMLT (Technical Officer B) Technical Staff Mr. Santosh Patkar, M.Sc, DMLT (Technician-II)
Dr. Sirin Khan, BDS, MPH, Scientist B (Medical) Mr. Alok Kushwaha, Poly Diploma IT (DEO-A) Mr. Suneel Prajapati, B.Sc, DMLT (Technician ‘C’) Ms. Amrita Upadhayay, M.Sc, DMLT (Field Investigator) Project Staff Mr. Ankit Tirkey, M.Sc (Field Investigator) Mr. Mukesh Sahu, M.Sc, DMLT (Field Investigator) Mr. Sohan Lal Prajapati, B.Sc, DMLT (Field Investigator)
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Acknowledgments
We are thankful to the Padma Shri Dr. Balram Bhargava, Secretary, Department of Health Research and Director General ICMR, for the financial assistance of the project. We express our sincere gratitude to Dr. Rupinder Singh Dhaliwal Scientist-G & Head NCD division for assigning the project to us and their continuous support during the project. We take this opportunity to thank our Director, Dr. Aparup Das ICMR-National Institute of Research in Tribal Health Jabalpur for his guidance, support and encouragement during the entire period of the study. We would like to thank Dr. Pankaj V. Uike (Project Scientist-C) for help in conducting cause of death survey and Mr. Lalit Sahare, Technical Officer B for helping us on the laboratory analysis of stool samples. Further the team would like to express sincere thanks to District Collector Raigarh, CMHO Raigarh, BMO of Tamnar Block and Mr. Shriram Bhagat Rural Health Officer for their all out help during the survey. We would also like to thank HR Division Jindal Power Limited (JPL) for providing accommodation to the team during the study period. We will fail in our duty if we do not thank to all the ASHA (Mitanin)/ANM workers who immensely helped during household surveys and tribals who participated in the study.
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List of Tables
Part-A Health Assessment of villagers
1 Distribution of socio-demographic factors of villagers 52
2 Age and sex distribution of the study population 55
3 Prevalence of major morbidities among pre-school children 55
4 Prevalence of major nutritional deficiency disorders among pre-school 56 children 5 Prevalence of major morbidities among school going children 56 (6-14 yrs) 6 Prevalence of nutritional deficiency disorder among school going children 57 (6-14 yrs) 7 Prevalence of major morbidities among villagers (Age > 15 yrs) 57
8 Prevalence of nutritional deficiency disorder among villagers (Age > 15 yrs) 58
9 Gender-wise distribution of systolic blood pressure according to (JNC VII 58 Classification) 10 Gender-wise distribution of diastolic blood pressure according to (JNC VII 58 Classification) 11 Age group-wise distribution of systolic blood pressure among the villagers 59
12 Age group-wise distribution of diastolic blood pressure among the villagers 60
13 Distribution of systolic blood pressure according to Body Mass Index 61
14 Distribution of diastolic blood pressure according to Body Mass Index 61
1 5 Distribution of systolic blood pressure according to income status 61
16 Distribution of diastolic blood pressure according to income status 62
17 Distribution of hemoglobin level according to age category among the 62 villagers
18 Percentage distribution of anaemia according to hemoglobin level among 63 pregnant women
19 Percentage distribution of worm infestations in school going children 63
20 Gender-wise percentage distribution of BMI as per James et al. classification 64 among the villagers
21 Percentage distribution of children according to SD Classification 64
22 Status of immunization coverage among children upto 5 years 65
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23 Distribution of immunization status among child of 12-23 months 65
24 Distribution of health services utilization: Antenatal care 65
25 Distribution of iron folic acid tablet supplementation 66
26 Distribution of health services utilization: Postnatal care 66
27 Distribution of households aware of Government Health program facilities 66
28 Distribution of household availing Pradhan Mantri Ujjwala Yojana 66
29 Percentage distribution of fluoride level in urine 67
30 Percentage distribution of fluoride level (> 2.1 PPM) in urine 67
Part-B Causes of death
1 Socio-demographic characteristics of adults 68
2 Socio-demographic characteristics of neonates 69
3 Socio-demographic characteristics of children 69
4 Causes of death - associated risk factors 70
5 Causes of death among adults according to four major categories as per ICD 71 10 6 Distribution of deaths in four major categories by gender 71
7 Distribution of deaths in four major categories by age category, 71
8 Overall distribution of causes of deaths as per ICD 10 categories 72
9 Causes of death by age category as per ICD 10 categories 73
10 Overall and gender-wise distribution of causes of death in the ICD 10 74 categories 11 Proportion of deaths in four major categories according to smoking status 76
12 Proportion of deaths in four major categories according to alcohol use 77
13 Proportion of deaths among neonates as per ICD 10 category 77
14 Place of deaths among neonates 77
15 Proportion of deaths among child as per ICD 10 category 78
16 Place of deaths among children 78
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List of Figures
Sr. Title Pg. No. No. 1 Age group-wise distribution of systolic blood pressure among the villagers 59 2 Age group-wise distribution of diastolic blood pressure among the villagers 60
3 Percentage distribution of anaemia among women (above 15 years of age) 63
4 Age-sex distribution of deceased in cause of death survey 34
5 Pre-existing diseases of the deceased 35
6 Cause of deaths according to four major categories 35
7 Overall distribution of cause of death 36
8 Cause of death according to sex distribution 37
9 Distribution of deaths according to age category 38
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Acronyms
ANM Auxiliary Nurse Midwife ADA American Diabetes Association ASHA Accredited Social Health Activist BPL Below Poverty Line CDC Center for Disease Control and Prevention CD Community Development Block CG Chhattishgarh CGHR Center for Global Health Research CHC Community Health Centre COPD Chronic Obstructive Pulmonary Disease DBP Diastolic Blood Pressure DH District Hospital DM Diabetes Mellitus DOTS Directly observed treatment, short course DPT Diptheria, Pertussis and Tetanus g/dL Grams per decilitre Hb Hemoglobin HH Household HT Hypertension IHD Ischemic Heart Disease IDSP Integrated Disease Surveillance Programme ICD International Classification of Diseases JNC Joint National Committee JSY Janani Suraksha Yojana MO Medical Officer M.leprae Mycobacterium leprae µL Microliter NCD Noncommunicable Disease NCHS National Center for Health Statistics NFHS National Family Health Survey NIRTH National Institute of Research in Tribal Health NNMB National Nutrition Monitoring Bureau mmHg Milimeters of Mercury OPV Oral Polio Vaccine PHC Primary Health Centre PPS Probability Proportional to Size RBS Random Blood Sugar RGI Registrar General of India RNTPC Revised National Tuberculosis Control Program SBP Systolic Blood Pressure SPSS Statistical Package for the Social Science ST Scheduled Tribes TB Tuberculosis TT Tetanus Toxoid TISAB Total ionic strength adjustment buffer UT Union territory VA Verbal Autopsy WHO World Health Organization
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Executive Summary Title: Health Assessment of Villagers of Tamnar Block, District Raigarh, Chhattisgarh Introduction: The morbidity profile provides an integral picture of the health and related conditions of any population. It helps in determining the priorities and accordingly in planning the nature and extent of health services to be provided on the available resources for achieving the desired result. Rational: A letter was received from Ministry of Environment and Forest and Climate Change, on the directives of National ST Commission to undertake a Study on Health Assessment and Projection of Health of People living in Tamnar Block, Raigarh, Chhattisgarh. Hence, the study was carried out to assess the Health & Nutritional status and cause of death among the tribe residing in Tamnar. Since, this is the first such study undertaken in this area. The study will help the local government in planning specific health programmes in this area and will also help in formulating disease-specific in-depth study later on. Objective: In this study, an attempt was made to find out the morbidity, mortality and nutritional status of the population residing in Tamnar Block of Raigarh District. Specific objectives were: 1. To study morbidity profile of the tribe residing in Tamnar Block of Raigarh District. 2. To assess the nutritional status through anthropometry 3. To assess the utilization pattern of various government health programmes by the community. Methodology: The study was carried on the directives of the National ST Commission in 33 sampled villages of Tamnar Block. The investigation included collection of data on demographic and socio-economic particulars of the households, anthropometry; clinical examination for general morbidity and nutritional deficiency disorders.Pulse, Blood Pressure, Random Blood Sugar were measured. Anthropometry like height was measured by SECA anthropometric rod, Weight was measured by a digital weighing scale by trained investigators. A similar number of children were also examined for the prevalence of various childhood morbidities. Results: A total of 5233 individuals covering 984 households from 33 villages were surveyed and 1713 individuals of different ages were thoroughly screened clinically. Thus the final analysis from the sample of 1713 is presented here. The majority of the population (61.2%) were using community piped water supply for drinking purposes. About 11.2% of the households had tube well as a source of drinking water, while 22.9% of households were using open well for drinking. About 91.1% of the household had sanitary latrines and about 99.8% of households were electrified. About 86.1% of the households were aware of Aayushman Bharat Yojana and 19.2 % had Aayushman Bharat Yojana card with them during the survey. Overall, 66.6% of households had liquid petroleum gas (LPG) connection through Pradhan Mantri Ujjwala Yojana. In general, the proportion of pre-school children with underweight (< -2SD) was about 42.7%. Among the adult population, about 8.8% of males and 6.6% of the ix | P a g e females had grade III chronic energy deficiency. Overall acute respiratory infection (20.9%) constituted the most common morbidity followed by fever (6.2%) and scabies (1.6%) among the pre-school children. The prevalence of knock knee (Genu valgum) was 5.7% and marasmus was 1.2%. The prevalence of hypertension was 21.8% followed by anaemia (16.1%) and fungal infection (4.0%) among the adult population. A majority of the currently pregnant women (98.6%) had received some kind of antenatal care. Out of total pregnant women (74), about 86.4% of women have received TT injection during their antenatal period. Among under-five years of children, BCG vaccination was 96.1% followed by DPT (95.8%). Major recommendations: 1. Prophylaxis programme for anaemia & malnutrition should be strengthened. 2. Health facilities should be strengthened and vacant post of specialist doctors and trained health workers should be filled as per IPHS guideline along with laboratory facilities in CHC and PHC. 3. Initiative for provision for safe drinking water especially in two villages Mudagaon and Saraitola (i.e. fluoride free, arsenic free or other geogenic contamination). 4. Intervention programmes for NCDs especially for hypertension and other cardiovascular diseases should be undertaken.
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Summary of Health Assessment The morbidity profile provides an integral picture of the health and related conditions of any population. It helps in determining the priorities and accordingly in planning the nature and extent of health services to be provided on the available resources for achieving the desired result. In this study, an attempt was made to find out the morbidity, mortality and nutritional status of the population residing in Tamnar Block of Raigarh District. The study was carried on the directives of the National ST Commission in 33 sampled villages of Tamnar Block. The investigation included collection of data on demographic and socio-economic particulars of the households, anthropometry; clinical examination for general morbidity and nutritional deficiency disorders. About 1713 individuals of different ages from 984 households in 33 villages were surveyed. The majority of the household belongs to the Hindu religion (99.5%) followed by Christianity (0.4%) and Muslim (0.1%). About 60.4% of the households were living in Kuchcha houses. Farming was the major occupation (13.8%). About 24.5% population had primary education while 5.8% was illiterate and 21.4% had middle-level education. The majority of the population (61.2%) were using community piped water supply for drinking purposes. About 11.2% of the households had tube well as a source of drinking water, while 22.9% of households were using open well for drinking. About 91.1% of the household had sanitary latrines and about 99.8% of households were electrified. About 86.1% of the households were aware of Aayushman Bharat Yojana and 19.2 % had Aayushman Bharat Yojana card with them during the survey. Overall, 66.6% of households had liquid petroleum gas (LPG) connection through Pradhan Mantri Ujjwala Yojana. In general, the proportion of pre-school children with underweight (< -2SD) was about 42.7%, while that of severe underweight (< -3SD) was 12.8%. The extent of stunting (< -2SD) was about 32.8% while about 13.4% were severely stunted. Wasting (< -2SD) were 14.1% and severely wasted (< -3SD) were 3.5%. Among the adult population, about 8.8% of males and 6.6% of the females had grade III chronic energy deficiency. Overall acute respiratory infection (20.9%) constituted the most common morbidity followed by fever (6.2%) and scabies (1.6%) among the pre- school children. The prevalence of knock knee (Genu valgum) was 5.7% and marasmus was 1.2%. The prevalence of hypertension was 21.8% followed by anaemia (16.1%) and fungal infection (4.0%) among the adult population.
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A majority of the currently pregnant women (98.6%) had received some kind of antenatal care. Out of total pregnant women (74), about 86.4% of women have received TT injection during their antenatal period. Among under-five years of children, BCG vaccination was 96.1% followed by DPT (95.8%).
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Summary of cause of death
We have conducted a cause of death survey in Tamnar block, Raigarh district, Chhattisgarh. The state has about more than one-fourth of the Scheduled Tribes (ST) population (30.62%) as per the 2011 census. We have conducted community-based cross-sectional survey of 253 deaths that occurred in the previous one year. Out of 253 deaths, 230 were adults more than fifteen years of age, 13 were neonatal and 10 were children. Overall 63.9% of the deceased were above 60 years of age, 17.4% had the educational standard of class 1-5 and BPL card holders were 86%. Most of the deaths occurred at home (78.3%). Alcohol consumption (33.9%) and smoking habit (27%) among the deceased were prevalent, the proportion being higher among males as compared to females. Hypertension (30%) was the leading pre-existing disease followed by diabetes (12.6%), stroke (8.3%) and tuberculosis (4.3%).
Overall, noncommunicable diseases accounted for more than half of the deaths (53%), infectious and parasitic diseases (14%), injuries and suicide (12%) while 20% of deaths were not elsewhere classifiable which include ill-defined and unknown cause of mortality, age-related physical debility, unspecified abdominal pain, diarrhoea and fever unspecified. Among NCDs, cardiovascular diseases (34.3%) were the leading cause of death followed by digestive diseases which include alcoholic liver diseases (6.5%). Neoplasm caused 4.7% of deaths. Infectious and parasitic diseases accounted for 13.9% of total deaths, tuberculosis (7.8%) was the major cause of death in infectious and parasitic diseases category. External causes including suicide and injuries caused 12.2% of total deaths; suicide accounted for 4.3% of the deaths.
Among neonatal deaths, birth asphyxia accounted for six deaths followed by stillbirths which caused three deaths. Among child deaths, 60% were under 5 years of age. Overall deaths due to hemolytic anaemia (1), sickle cell anaemia (1) and thalassemia (1) caused three deaths followed by diarrhoea (2), cerebral palsy (1) and epilepsy (1).
Noncommunicable diseases should be controlled by keeping as a health priority in Tamnar block, Raigarh district. Primary and secondary care facilities should be strengthened to provide screening and treatment for hypertension, diabetes mellitus and cancer and should have proper infrastructure for management of acute coronary syndromes, stroke and injuries to reduce mortality. Mental health program needs to be strengthened for early detection of depression especially among the younger xiii | P a g e population to prevent suicides. There is a need for community-based interventions to reduce alcohol consumption and sensitization of health providers for providing appropriate treatment and counseling for patients with alcohol use disorders.
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Definitions Body Mass Index (BMI): BMI is an index of weight for the height that is commonly used to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of height in meters (kg/m2). Hypertension: A condition in which the force of blood against artery walls is too high. An individual is said to be hypertensive when systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg or taking antihypertensive drugs. Diabetes: Patient on drug treatment for diabetes or laboratory record of fasting plasma glucose > 126 mg% and/or postprandial plasma glucose > 200 mg% (as per ADA definition) or history of hospitalization for complications of diabetes. Cardiovascular Diseases: Patient on drug treatment for Stroke/Ischemic Heart Disease or history of CABG/Angioplasty or clinical record with ECG evidence of cardiovascular disease or history of hospitalization for the acute coronary syndrome/myocardial infarction/stroke. Tuberculosis: A confirmed case of TB who has symptoms of productive cough for more than 2 weeks and has positive sputum smear or individual on Anti-tubercular treatment (ATT). Chronic Obstructive Pulmonary Disease (COPD): is a lung disease characterized by chronic obstruction of lung airflow that interferes with the normal breathing and is not fully reversible. Emphysema and chronic bronchitis are the most common conditions. Leprosy: According to WHO Case definition of leprosy is M. leprae infection in an individual who has not completed a course of treatment and has one or more of the following: hypopigmented or reddish skin lesion with loss of sensation; involvement of peripheral nerves; skin smear positive for acid-fast bacilli. Anaemia: Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking and pregnancy. Malnutrition: Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. Fluorosis: Ingestion of excess fluoride, most commonly in drinking water can cause fluorosis which affects the teeth and bones. Cerebral Palsy: Cerebral Palsy is a disorder of the development of movement and posture, causing activity limitations attributed to nonprogressive disturbances of the
xv | P a g e fetal or infant brain that may also affect sensation, perception, cognition, communication, and behavior. It is caused by a non-progressive brain injury or malformation. Smoker: A person who smoked/used tobacco in any form either daily or occasionally in the previous 30 days. Alcohol use: A person who consumes alcohol in any form either daily or occasionally in the previous 30 days. Below Poverty Line (BPL): A family called BPL when total income per annum of the family was less than Rs. 27, 000 or whose monthly income was less than Rs. 2250.
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Contents Page no 1. INTRODUCTION ...... 1 2. OBJECTIVES ...... 5 3. METHODOLOGY ...... 6 PART-A: HEALTH ASSESSMENT OF VILLAGERS ...... 6 3.1. STUDY DESIGN...... 6
3.2. SAMPLE SIZE ...... 6
3.3. SAMPLING DESIGN ...... 6
3.4. TRAINING AND STANDARDIZATION ...... 7
3.5. ETHICAL ISSUES ...... 9
3.6. DATA COLLECTION ...... 9 PART-B: METHODOLOGY OF THE CAUSE OF DEATH STUDY ...... 14 3.7. STUDY AREA...... 14
3.8. STUDY DESIGN AND POPULATION ...... 14
3.9. DATA COLLECTION TOOL ...... 14
3.10. DATA COLLECTION PROCEDURE ...... 15
3.11. DATA ANALYSIS ...... 15 4. DATA ANALYSIS ...... 16 4.1. ANTHROPOMETRY ...... 16
4.2. DIABETES ...... 17
4.3. FLUOROSIS CLASSIFICATION (DENTAL AND SKELETAL) ...... 17
4.4. ANAEMIA ...... 18
4.5. HYPERTENSION ...... 18 5. RESULTS ...... 19 PART-A: HEALTH ASSESSMENT OF VILLAGERS ...... 19 5.1. COVERAGE ...... 19
5.2. DEMOGRAPHIC PROFILE ...... 19
5.3. CLINICAL EXAMINATION...... 20
5.4. NUTRITIONAL STATUS ...... 31
5.5. HEALTH SERVICE ...... 31 PART-B: CAUSE OF DEATH ...... 33 5.6. SOCIO-DEMOGRAPHIC CHARACTERISTICS ...... 33
5.7. RISK FACTORS ...... 33
5.8. CAUSE OF DEATH DISTRIBUTION ...... 34
5.9. CAUSE OF DEATHS BY GENDER AND AGE-WISE ...... 36
5.10. NEONATAL DEATHS (0 DAYS TO 28 DAYS) ...... 37
5.11. CHILD DEATHS (29 DAYS TO 14 YEARS) ...... 37 6. DISCUSSIONS ...... 39 7. CONCLUSIONS ...... 43 8. RECOMMENDATIONS ...... 44 9. REFERENCES ...... 45 10. ANNEXURES ...... 49 1 | P a g e
1. Introduction
The tribal population of the country, as per the 2011 census, is 10.43 Crore, constituting 8.6% of the total population. 89.9% of them live in rural areas and 10.03% in urban areas. The decadal population growth of the tribal’s from Census 2001 to 2011 has been 23.66% against 17.7% of the entire population.1 There are forty-two (42) tribes in C.G. Gond is the most populous tribe, constituting 55.3% of the total ST population followed by the Kawar, Oraon, Halba, and Bhattra. These five Scheduled tribes constitute 84.3% of the total ST population of the State. At the district level, Gonds have registered their high population in Bastar, Dantewada, Kanker, Surguja and Raipur districts. Kawars are mainly concentrated in Surguja, Raigarh and Korba districts.2 Raigarh district is situated in the easternmost part of Chhattisgarh state. It is bounded by Surguja and Jashpur districts in the north, Orissa in the east, Mahasamund district in the south and Korba and Janjgir-Champa districts in the west. The total geographical area of the district is 7,086 sq. kms. Raigarh district is full of major minerals like Coal, Quartzite, Limestone and Dolomite. As per Census 2011, there were nine Tahsils and equal numbers of Community Development Blocks (CD Blocks) in Raigarh district. The total number of villages in the district is 1466 which includes 1426 inhabited villages and 40 uninhabited villages. The total population of Raigarh district is 14,93,984 with 7,50,278 males and 7,43,706 females. Rural population is 12,47,682 and Urban population is 2,46,302. The literacy rate of the district of Raigarh in the Census 2011 is 73.26% (male 83.49% and female 63.02%). The proportion of Scheduled Tribes (ST) population in the district is 33.84% in Census 2011.3Tamnaris a Block (CD) in the Raigarh district of Chhattisgarh. The total area of Tamnar is 729 km². The latitude 22.0882047 and longitude 83.4387589 are the geo-coordinate of the Tamnar. According to Census 2011 information, Tamnar has a population of 97,975 peoples (49,342 males and 48,633 females). There are 23,963 houses spread over in 116 villages.4 Nearby mining activities put the tribal population of Raigarh at increased risk of diseases such as acute respiratory infection (ARI), tuberculosis, road traffic accident (RTA), etc. Apart from environmental health hazards, undernutrition increases the risk further for various diseases. Kelo river in Tamnar is polluted due to waste disposal from mining activities.5
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Plate 2, A view of Tamnar Block
A Typical Village Open Mines Near Bajarmuda Village
Mines Near Sarasmal Village Industrial Waste Near Pata Village
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Justification/Need of the Study
A letter was received from Ministry of Environment and Forest and Climate Change, on the directives of National ST Commission to undertake a Study on Health Assessment and Projection of Health of People living in Tamnar Block, Raigarh, Chhattisgarh. Hence, the study was carried out to assess the Health & Nutritional status and cause of death among the tribe residing in Tamnar. Since, this is the first such study undertaken in this area. The study will help the local government in planning specific health programmes in this area and will also help in formulating disease-specific in-depth study later on.
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2. Objectives
2.1. To studymorbidity profile of the tribe residing in Tamnar Block of Raigarh District 2.2. To assess the nutritional status through anthropometry. 2.3.To assess the utilization pattern of various government health programmes by the community.
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3. Methodology
Part-A: Health Assessment of villagers
3.1. Study Design
This was a cross-sectional study.
3.2. Sample Size
According to census 2011, the total population of Tamnar Block is 97,975. We assumed an increase of 10% population in 2018. Thus, the present population is likely to be 107772. Using “Right Size” statistical software of CDC Atlanta, we considered 50% proportion of the diseased (since there has been no study done earlier) in the target population, with a cluster size of 20, with a confidence coefficient of 90% and confidence interval of + 10%, with 0.3 rate of homogeneity and design effect of 6.70, a total of about 660 response was required from 33 clusters. In addition of 10% non-respondent were required for the final sample size of 726 for morbidity profile of adults. Similarly, an equal number of children were required to study the prevalence of various childhood morbidities. Based on the NFHS-4 data, we estimated that a minimum 10% of the adult individuals are likely to be diabetic, hence using simple random sampling a total of 138 adults were covered for random blood sugar (RBS). Similarly, with an assumption that worm infestation is likely to be 10% among school children minimum of 138 stool samples were collected for microscopic examination.
3.3. Sampling Design
A total of 33 clusters (village) were selected by probability proportional to size (PPS) sampling from the total village list of 116. In each cluster, every 4th or 5th household was selected, depending on the size of the village, availability of adults in the household and consent from the respondent in a village, we tried to cover each and every hamlet (para). In the selected household, 2 respondents (one adult and one child) were selected by simple random sampling. About 10% of the adult individuals are likely to be diabetic; hence using simple random sampling a total of minimum 138 adults were covered for Random Blood Sugar.
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Similarly with an assumption, worm infestation is likely to be 10% among school children a minimum of 138 stool samples were collected for microscopic examination. List of 33 selected villages: Tihli Rampur, Kunjemura, Gare, Saraitola, Mudagaon, Rodopali, Pata, Chitwahi, Dholnara, Jhinkabahal, Dolesara, Bhalumura, Sarasmal, Libra, Deogaon, Mahloi, Samkera, Jobaro, Uraba, Pelma, Bajarmuda, Hamirpur, Dongamahua, Kodkel, Budiya, Kasdol, Jarekela, Nawapara, Tamnar A, Tamnar B, Barpali, Amapali, Taraimal.
I. Flow Chart showing Sample Design
Raigarh
Tamnar Block
116 Villages
PPS Sampling
33 (Clusters) Villages
3.4. Training and Standardization
All the staff including Medical officer, Scientist, field investigators and lab technicians of the project were trained and standardized at ICMR-NIRTH Jabalpur, in all aspects of the project for a period of one week in various techniques of investigation such as data collection, anthropometry, haemoglobin (Hb) estimation, stool examination for the presence of ova and cyst and measurement of blood pressure etc. by principal investigator and Head of the NCD division.
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Plate 3
Directors Visit at Village Mudagaon Meeting with BMO at CHC- in Tamnar Block Tamnar, Raigarh
Training of Staff and Field Investigators at NIRTH, Jabalpur, M.P.
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3.5. Ethical Issues
The study protocol was submitted to the Scientific Advisory Committee and Institutional Ethics Committee and approved with IEC No. Tribal/114/2018-ECD-II, dated 10/1/2019. Informed written consent was obtained from all the subjects who participated in the study and who gave blood for Hb estimation, Random Blood Sugar and Malaria spot testing. Patients with acute medical conditions/illness were treated on the spot while other patients requiring prolonged treatment were referred to the nearest Government Health Center. Patients with confirmed tuberculosis diagnosis were followed and the team ensured that the patient had started medicine (DOTS) from the nearest health facility.
3.6. Data Collection
Trained investigators collected data on the census by the house to house survey in a pretested semi-structured questionnaire by personal interview.
3.6.1. Household Particulars
Demographic and socio-economic particulars such as age, sex, occupation, income, and literacy level of all the individuals were collected from the selected households by personal interview in a pre-coded proforma.
3.6.2. Clinical Examination
All the available willing individuals were examined clinically by a Medical officer for the presence of signs of general morbidities such as fever, scabies, dysentery, diarrheoa, acute respiratory infection, itching, rashes, hypo/hyperpigmented patches etc. during the preceding 15 days of data collection. Chronic disease condition was examined such as hypertension, diabetes, fluorosis, chronic cough for more than 14 days, etc. by collecting data of the past 6 month’s history.
3.6.3. Anthropometry
Anthropometric measurement such as height was measured in cm (error of margin up to 1 cm) and weight was taken in kg by using SECA digital balance (error of margin up to 100 gm) and Anthropometric rod by a trained investigator.
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Plate 5, Showing Anthropometric Measurement by Field staff at Tamnar Block, Raigarh C.G.2019
3.6.4. Malaria Testing
Those who were suffering from fever, spot malaria test was done using BD Rapid Diagnostic kit and also peripheral blood smear was made by a trained fieldworker and technician.
3.6.5. Blood Pressure
Systolic and diastolic blood pressures were measured in sitting posture using a digital sphygmomanometer (Omron HEM 7120 Fully Automatic Digital Blood Pressure Monitor) to all available adults. The measurement was done for three consecutive reading, with a gap of 3 minutes between measurements. The mean blood pressure of all the three readings was recorded.
3.6.6. Blood Sugar Measurement
Random blood sugar was measured by SD-Code free Blood glucometer in 10% of the adults in the field.
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Plate 5, Showing Blood Pressure Measurement and Blood Sugar Measurement by Field staff at Tamnar Block, Raigarh
3.6.7. Stool ova cyst Examination
Stool samples were collected from the willing children in stool collection bottles (Hi media). Samples were collected in 10% formaldehyde solution and processed by Formalin-ether concentration method for the identification of ova and cyst.
Plate 6, Showing Stool Collection and Laboratory Examination of Stool Sample
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Flowchart Showing Stool Examination (Formalin-ether concentration method)
Take about 1gm stool in test tube
Add 7.0 ml 10% formalin & mix well
Strain through wire gauge and collect the filtrate in centrifuge tube
Add 3.0 ml ether in the filtrate and vigorously for1 min.
Centrifuge at 2000 RPM for 2-3 mins.& allow the contents to settle
Remove supernatant leaving 1 - 2 drops
Place mixed deposit on slide & place cover slip on it
Examine under microscope
Result
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3.6.8. Hb estimation
Modified Cyanmethaemoglobin method was chosen for the study. Twenty μl of blood was measured accurately from a pre-calibrated Hb pipette and delivered on to a Whatman no. 1 filter paper. The filter paper is air-dried, labelled and brought to the main laboratory for estimation of haemoglobin. Since the dilution is enormous (251 times) accurate measurement of twenty μl of blood was absolutely essential for reproducibility.
3.6.9. Sputum Examination and X-ray Chest Examination
All symptomatic individuals for tuberculosis, smear were made in the field and brought to ICMR-NIRTH main laboratory for AFB examination. X-ray of suspected TB patient was taken in CHC- Tamnar under the supervision of the Medical officer of Tamnar Block.
3.6.10. Water Fluoride and Urine Examination
Urine and water samples were collected from the field and transported to ICMR- NIRTH, Jabalpur for lab investigation. 0.9ml of water/urine sample was mixed with TISABIII buffer solution and tests were performed using ION meter.
Plate 7, Showing Water Sample Collection from Various Sources at Tamnar Block, Raigarh
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Part-B: Methodology of the cause of death study
The cause of death information in India is poor, particularly in tribal areas too poor, due to low awareness on health issues as well as a shortage of medical and personal facilities in tribal regions. So, for in tribal-dominated areas the most people do not die in health facilities. Therefore, quantifying the disease for the cause of death data based on the “Medical Certification of Cause Death” insufficient to represent the “Tribal death data” accurately. 3.7. Study Area
We have conducted the cause of death survey in the 33 villages of Tamnar Block.
3.8. Study Design and Population
We conducted a community based cross-sectional survey of deaths that occurred in the previous one year; the period from 1st December 2018 to 30th November 2019.
3.9. Data Collection Tool
We used the registrar general of India /centre for global health research (RGI/CGHR) verbal autopsy (VA) tool for ascertaining the cause of death.13The signs and symptoms preceding death were collected by using verbal autopsy form (10A, 10B, 10C, 10D) available at the global health (CGHR) web site. Here verbal autopsy forms (2011 version) for different age groups were available. We selected the same 33 villages (which were selected for the morbidity profile) and obtained a list of all the deaths which occurred in the previous year. Informed written consent was obtained from the participants. Participant information sheet and consent form were explained by the investigators and a thumb impression was taken for participants who could not read/write. We have collected information about the deceased about the socio- demographic status and other relevant information (e.g., place of death). We also enquired regarding the medical history of pre-existing diseases, treatment history (medication, hospitalization, etc) and risk behaviours (e.g. smoking, alcohol, etc).
Form 10A - Neonatal Death (28 days or less of age)
Form 10B - Child Death (29 days to 14 years)
Form 10C - Adult Deaths (15 years and above)
Form 10D - Maternal Death (Female aged 15 to 49) 14 | P a g e
3.10. Data Collection Procedure
We have obtained the list of deaths for the reference period of one year from multiple sources like ANM/ASHA/Health worker/Sarpanch/Local leaders etc. in each cluster. We approached the family of the deceased and after taking informed consent, administered the semi-structured verbal autopsy questionnaire to the family member who was closest to the deceased before the terminal illness.
3.11. Data Analysis
We have entered the data into MS Access and analyzed using SPSS (version 25). The cause of death and ICD 10 code14 was assigned independently by two medical doctors, in case of dispute with the diagnosis opinion of the third doctor was obtained to find out the possible cause of death. The proportion of deaths due to each disease was computed in various age groups and among both sexes.
15 | P a g e
4. Data Analysis
4.1. Anthropometry
Standard Deviation (SD) Classification The weight and height of children were compared with those National Center for Health Statistics (NCHS) for grading their nutritional status according to SD classification. The World Health Organization recommended the standard deviation (SD) classification to categories the children in different grades of nutritional status. The present distribution of pre-school children according to underweight (weight for age) stunting (height for age) and wasting (weight for height) was computed using National Centre for Health Statistics (NCHS) reference given below. SD Classification SD Classification Weight for age Height for age Weight for Height >Median -2SD Normal Normal Normal Median-2SD Moderate Moderate Moderate wasting to>Median -3SD undernutrition stunting The nutritional status of an adult was assessed based on Body Mass Index (BMI) according to BMI for Asian Indians,7 which is a ratio of weight in kg to the square of heights in meters. The adults were categorized into different grades according to different nutritional grades according to James at al. classification8 and that of WHO Consultative group as below: Body Mass Indices for Aisan Indians Classification BMI Nutritional Grade Classification < 16.0 III Degree CED 16.0-17.0 II Degree CED James et al. 17.0-18.5 I Degree CED 18.5-20.0 Low Normal 20.0-25.0 Normal 25.0-30.0 Overweight > 30.0 Obesity 16 | P a g e 4.2. Diabetes Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Diabetes may present with characteristic symptoms such as polydipsia (excessive thirst), polyuria, blurring of vision, and weight loss. We had examined Random (also called Casual) Blood Sugar using SD-Code free Blood glucometer in 10% adults at the field. Diabetes is diagnosed at a blood sugar of greater than or equal to 200 mg/dl(11.1 mmol/L) and with the presence of characteristic symptoms of hyperglycemia or hyperglycemic crisis.9 (According to ADA 2017 Classification and Diagnosis of Diabetes) 4.3. Fluorosis Classification (Dental and Skeletal) Dental Flourosis Ingestion of fluoride is the cause of dental fluorosis. Fluoride in the drinking water, food, tooth paste etc. can contribute to the fluoride burden of the body leading to dental fluorosis. Affected teeth, become discolored which will be away from the gums and on the enamel surfaces and can never be removed as an integral part of tooth matrix. Skeletal Fluorosis Excess fluoride entering the body mainly through drinking water, food items, drugs and cosmetics (toothpaste, mouth rinses and tablets) can cause skeletal fluorosis. Skeletal fluorosis manifestations are seen in the young as well as in the adults. Major symptoms include pain in the neck, back, joints and rigidity begin in cancellous bones. In severe cases, there is complete rigidity of joints resulting in stiff spine and immobile knees, pelvic and shoulder joints. Spot urinary fluoride excretion of selected affected individuals has been examined to estimate the fluoride level. The safe limit of fluoride in drinking water is 1.00mg/L (According to BIS standard).12 Ministry of Drinking Water and Sanitation, Government of India permits up to 1.50 mg/L, however lesser the better.12 The normal limit of fluoride in urine is 0.10 mg/L.12 17 | P a g e 4.4. Anaemia The criteria suggested by WHO were used to define the extent and degree of anaemia10 for male and female are presented below: Gender Grades of Anaemia (Hb gm/dL) Non- Mild Moderate Severe Anaemia Male >13 11.0-12.9 8-10.9 <8 Non-Pregnant >12 11-11.9 8-10.9 <8 Pregnant women >11 10-10.9 7-9.9 <7 Children 6-59 >11 10-10.9 7-9.9 <7 months Children >11.5 11.0-11.4 8.0-10.9 <8 5-11years Children >12 11.0-11.9 8.0-10.9 <8 12-14years In our study, for childrens 6-14 years we have categorized them as Non-anaemic >12gm/dL, mild 10-11.9gm/dL, moderate 7.0-9.9 gm/dL and severe <7gm/dL. 4.5. Hypertension Individuals with systolic blood pressure of >140 mmHg and diastolic pressure of >90 mmHg were considered as hypertensive11 (WHO-TRs 862, 1966 & JNC Criteria VII) According to JNC (VII) Classification Blood Pressure (mm/Hg) Grade of Hypertension Systolic Diastolic Normal <120 <80 Pre Hypertension 120-139 80-89 Stage I Hypertension 140-160 90-99 Stage II Hypertension >160 >100 18 | P a g e 5. Results Part-A: Health Assessment of villagers 5.1. Coverage Total 1713 individuals were selected from 984 households (total population of the selected household was 5233 with an average family size of 5.3) were covered from 33 selected villages of Tamnar Blocks for clinical examination and anthropometry. The mean age was 21.1+1.6 SD years. Out of 1713, 1058 female and 655 male were participated in the study. A total of 448 blood samples were collected for estimation of haemoglobin. About 267 stool samples were collected for identification of intestinal parasites from children less than 14 years of age (Table 1). 5.2. Demographic Profile 5.2.1. Type of Family Most of the families were nuclear family (58.3%) and only 41.7% were joint family (Table 1). 5.2.2. Literacy Status of the Household About 5.8% of study participants were illiterate. About 24.5% had primary education, 21.4% had middle-level education, 13.3% had a high school education and only 4.3% had college-level education (Table 1). 5.2.3. Type of House The type of house was considered as an index of economic status of households. Majority of population (60.4%) lived in kuchcha house followed by semi-pucca 31.8% & only 7.8% population lived in pucca house (Table 1). 5.2.4. Religion and Caste of the Head of Household Most of the villagers (99.5%) of Tamnar block belong to the Hindu religion followed by Christianity (0.4%) and Muslim (0.1%). The majority of the population belongs to Scheduled Tribes (ST) 50.3% followed by OBC (30.9%), Scheduled Caste (16.4%) and General 2.4% (Table 1). 19 | P a g e 5.2.5. Occupation of the Household A majority of villagers 13.8% were farmers or marginal landholders. About 7.7% head of households were daily wage earner, 7.6% were a private employee and only 2.3% were in government service (Table 1). 5.2.6. Other Facilities A Majority of the populations (61.2%) were using community water supply for drinking purpose. About 11.2% of the households use tube well as a drinking water source and 22.9% depends on open well. About 91.1% of households had sanitary latrines. Almost 100% of households had electrification. A majority of the households were using firewood (82.6%) for cooking whereas 8.6% were using gas, 3.4% were using coal and only 1.9% used cow dung as cooking fuel (Table 1). 5.2.7. Alcohol Use The overall prevalence of alcohol use was 8.8%. Use of alcohol was more among males (52.5%) as compared to females (47.5%). 5.2.8. Smoking During the survey, the overall prevalence of smoking was 9.3%. Majority of smokers were males (92.8%) while 7.2% of females had the habit of smoking. Among the smokers, 88.1% were current smoker while 11.9% were Ex-smoker (Table 1). 5.3. Clinical Examination 5.3.1. General Morbidity A. Pre-school children The prevalence of morbidity are presented in Table 3. During the survey upper respiratory tract infection (20.9%) was found to be the most common morbidity in children, while 6.2% children had fever followed by anaemia (2.6%), diarrhoea& dysentery (2.4%) and scabies (1.6%). About 1.2% of children had a fungal infection during the survey. 20 | P a g e B. School going children Morbidity among school going childrens was presented in Table 5. The prevalence of acute respiratory infection was 14.1% followed by fever (4.6%). The overall prevalence of dental fluorosis and cerebral palsy was found to be 5.3% and 0.2% respectively among 6-14 years of age (Table 5). C. Adult Population The prevalence of morbidities is presented in Table 7. During the survey, hypertension (21.8 %) was found to be the most common morbidity followed by anaemia (16.1%), fungal infection (4.0%). Upper respiratory tract infection was 3.6%, diabetes (2.8%) and fever (2.6%). During the survey, the prevalence of skeletal fluorosis was 1.1% in age >15years (Table 7). 21 | P a g e Plate 12 Plate, A 6 year old and 36 year old Individual with skeletal fluorosis Plate, A 14 year old boy with Dental Plate, A 50 year old women with fluorosis Fungal Infection Plate, A 35 year old men with recurrent Plate, Patient with Symptom of TB fungal infection using multiple were taken to the hospital for X-ray antifungal ointments 22 | P a g e 5.3.2. Nutritional Deficiency Disorder The prevalence of clinical cases of Protein Energy Malnutrition such as Kwashiorkor in pre-school children was absent and 1.2% cases of Marasmus were seen. The prevalence of knock knee was 5.7% among the pre-school children and 7.9 % among the age groups of 6-14 years. The prevalence of dental caries among the age group 6- 14 years was 3.0% (Table 4 & 6). 5.3.3. Hypertension About 21.8% had hypertension (systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg or on antihypertensive treatment). According to JNC-VII criteria, the prevalence of stage I & II diastolic hypertension was about 17.9%. The overall prevalence of systolic hypertension (stage I & II) was 12.5%. The prevalence of diastolic blood pressure was more as compared to systolic blood pressure. Among males, the prevalence of systolic hypertension was 23.5% and 8.8% in females. While the prevalence of diastolic hypertension among males was 27.4% and 14.7% in females (Table 9 & 10). During the survey, about 49 (25%) patients were newly diagnosed with hypertension. The overall proportion of stage I & II systolic hypertension was 6.1%, whereas 11.1% of diastolic hypertension were found among the underweight (Table 13 & 14). The prevalence of stage I & II systolic and diastolic hypertension was found 10.3% and 14.7% among the families living below poverty line (BPL) respectively (Table 15 & 16). 5.3.4. Anaemia The overall prevalence of anaemia among women was 64.8%. Out of which, 30.6% was moderately anemic and 1.8% of women had severe anaemia(Figure 3). The overall prevalence of anaemia among pregnant women was 58.1% (Table 18). The overall prevalence of anaemia among 0-5 years children was 43.5% and 54% among 6-14 years children (Table 3 & 5). 23 | P a g e 5.3.5. Tuberculosis The reported cases of tuberculosis among age > 15 years was 2.0%. 5.3.6. Leprosy: The reported cases of leprosy among age > 15 years was 0.6%. 5.3.7. Skeletal Fluorosis: The prevalence of skeletal fluorosis among age > 15 years was 1.1% whereas 0.2% was found among 6-14 years of children (Table 7). 5.3.8. Cerebral Palsy: The prevalence of cerebral palsy among pre-school children was 0.7% and school going children was 0.2% (Table 3 & 5). 5.3.9. Fungal infection: The prevalence of fungal infection among age > 15 years was 4.0% (Table 7). 5.3.10. Worm Infestation About 267 stool samples were collected from school children less than 14 years of age. The overall prevalence of worm infestations among children was 33.3%. Entamoeba Coli (17.3%) was found to be the commonest worm infestation, although it has the least pathogenic activity followed by roundworm (10.9%), hookworm (2.9%) and threadworm (1.1%). Mixed infestations of roundworm with Entamoeba coli were 1.1% (Table 19). 24 | P a g e A Plate showing Egg of Enterobiusvermicularies A Plate showing Egg of Hook Worm A Plate showing Egg of Entameoba Coli A Plate showing Fertilized Egg of Ascaries 25 | P a g e 5.3.11. Fluoride Test Water and urine fluoride level has been estimated at NIRTH, Jabalpur laboratory. A totalof 38 water samples, from Saraitola (19) and Mudagaon (19) respectively were tested as these were the villages were clinical cases of dental and skeletal fluorosis were found, out of which 13 (34.2%) samples had a value above the recommended standard (>1.50mg/L). These are the fluoride affected villages of Tamnar Block. Water samples were collected from various sources such as open well, tube well, community water supply, hand pump and RO plant. A total of 30 urine samples were examined for urine fluoride level. Out of which 12 samples had values between 0.10-2.0 PPM and 18 samples had values more than 2.1 PPM. In Mudagaon, 14 urine samples were examined for the fluoridelevel, out of which 12 samples had urinary fluoridelevel more than the value >2.1 mg/L. Five samples from Saraitola and one samples from Kodkel had urinary flouridelevel more than the value >2.1 (Table 29 & 30). 26 | P a g e 27 | P a g e 28 | P a g e 29 | P a g e 30 | P a g e 5.4. Nutritional Status 5.4.1. Anthropometry The proportion of children with severe underweight (< Median -3SD) was about 12.8% while that of underweight (< -2SD) was about 42.7%. The extent of stunting (< -2SD) among pre-school children was 32.8% and severe stunting (< -3SD) was 13.4%. The magnitude of wasting among pre-school children was about 14.1% (< - 2SD), while that of severely wasting (< -3SD) were 3.5% (Table 21). 5.4.2. BMI Classification The distribution of adult man and women according to their Body Mass Index (BMI) grades is given in Table 21. Body Mass Index describes the current nutritional status of adults. About 13.2% of the males and 15.5% of the females had I degree CED (17- 18.5). The Prevalence of overweight was 11.0% among adult males and 12.0 % among females. About 2.7 % of the female were obese and 2.6 % male were obese (Table 20). 5.5. Health Service The health manpower in the position of Tamnar Block is poor. Large numbers of posts were vacant for specialist medical officers (72.7%) including a gynaecologist, surgeon, pediatrics, anaesthetist, etc. About 46.6% of nurses and 30% paramedical post were vacant at the facility. The blood storage facility was not available at the facility. 5.5.1. Maternal & Child Health The child survival and safe motherhood program was planned to provide a number of basic preventive services to save maternal and child mortality. One of such schemes is “Janani SuraksaYojna”. Under this scheme, any women can go to any govt. or recognized private hospitals for delivery. The women and the motivator were being paid a substantial amount immediately after discharge. About 58.3% of women were benefited from the JSY scheme. The reasons behind not utilizing the scheme were home delivery is more convenient (11.0%), don’t know about the policy (4.1%) and the hospital is far away (4.4%). 31 | P a g e 5.5.2. Immunization Among 0-5 year children, about 96.1% of children received BCG within one month of birth and 95.8 % children received dose of DPT. About 95.4% of children received the oral polio vaccine. Overall 93.6% of children received measles vaccine and supplementation of the vitamin A solution was 92.7% (Table 22). 5.5.3. Antenatal Care Among pregnant women (74), 98.6% received some antenatal care whereas 86.4% received Tetanus Toxoid injection. Overall 32.8% received 50-80 iron-folic acid tablets and only 20.9% had received more than 80 iron-folic acid tablets (Table 24 & 25). 5.5.4. Postnatal Care More than three-fourth of deliveries (77.5%) was carried out at the Government Hospital. About 12.0% of the deliveries were carried out at home(Table 26). 32 | P a g e Part-B: Cause of death 5.6. Socio-demographic Characteristics We have conducted a verbal autopsy for 253 deaths and assigned the cause of death as per ICD 10 coding. Among 253 deaths, 230 deaths were adults, 13 deaths were neonatal and 10 were child deaths. Among 230 adult deaths, 53.1% males and 46.9% females were above 60 years of the age (Figure 1). Overall, 60.4% of adult deceased never attended school. The major religion was Hindu (99.6%). Overall 86.1% of deceased had BPL card with 76.1% living in Kuchcha houses. The home was the most common place of death for more than three-fourth of the deceased (78.3%) (Annexure part B - table 1 & 4). Figure 1: Age-sex distribution of deceased in cause of death survey, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) 100% 90% 53.1 46.9 80% 70% 64.9 60% 35.1 50% 40% 70.8 30% 29.2 20% 10% 68.2 31.8 0% Male (n=134) Female (n=96) 15-29 years (n=22) 30-44 years (n=24) 45-59 years (n=37) 60 years & above (n=147) 5.7. Risk factors Alcohol consumption was prevalent among 33.9% of deceased whereas 27% of deceased had smoking habits in the past 5 years prior death and 38.3% of deceased used to have smokeless tobacco. Overall, hypertension (30%) was the leading pre-existing disease followed by diabetes (12.6%), stroke (8.3%), tuberculosis (4.3%), chronic respiratory disease (3%) and heart disease and cancer (2.6%) respectively (Figure 2) (Annexure part B - table 4). 33 | P a g e Figure 2: Pre-existing diseases of the deceased, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Hypertension Diabetes Stroke Tuberculosis Chronic respiratory disease Cancer Heart disease HIV/ AIDS 0% 5% 10% 15% 20% 25% 30% 35% 5.8. Cause of death distribution Overall, non-communicable diseases accounted for more than half of the deaths (53.9%). Infectious and parasitic diseases caused 13.9 % of deaths whereas injuries and suicides accounted for 12.1% deaths. Not elsewhere classifiable caused 20% of total deaths which includes ill-defined and unknown cause of mortality, age-related physical debility, unspecified abdominal pain, diarrhea and fever unspecified (Figure 3). Figure 3: Cause of deaths according to four major categories, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Not elsewhere classifiable Noncommunicable Diseases 20% 54% Injuries and suicide 12% 14% Infectious & parasitic diseases 34 | P a g e Figure 4: Overall distribution of cause of death, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Neoplasm Cardiovascular diseases Chronic respiratory diseases 5% Digestive diseases including cirrhosis and other chronic liver diseases 20% Neurological & Mental and substance use disorder Diabetes and endocrine diseases 4% 34% Kidney disorders Other noncommunicable diseases 8% Tuberculosis & HIV/AIDS 5% Malaria 1% 8% 6% Other common Infectious diseases & 3%3% 1% maternal Transports & unintetional injuries 1% 1% Suicide and interpersonal violance Not elsewhere classifiable Overall, cardiovascular diseases (34.3%) were the leading cause of death. In non- communicable diseases, neoplasm caused 4.7% of deaths. Digestive diseases accounted for 6.5% of deaths whereas diabetes and kidney diseases caused 2.6% of deaths respectively. Deaths due to chronic respiratory diseases accounted for 0.8% of deaths. In the broad category of infectious diseases, tuberculosis (7.8%) was the leading cause of death followed by common infectious diseases (4.7%) which includes sepsis, typhoid fever, viral hepatitis, whereas only two deaths occurred due to malaria. Deaths due to suicide and interpersonal violence were 4.3% and transport and unintentional injuries accounted for 7.8% of total deaths (Figure 4). 35 | P a g e 5.9. Cause of deaths by gender and age-wise The overall proportion of deaths due to cardiovascular diseases, digestive diseases and diabetes and endocrine diseases were higher among males as compared to females whereas the proportion of deaths due to chronic respiratory diseases and external causes includes transport and unintentional injuries were higher among females as compared to males (Figure 5). Figure 5: Cause of death according to sex distribution, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Cardiovascular 100% Neoplasm diseases 90% Chronic respiratory Digestive diseases diseases 80% Neurological Mental and substance 70% disorders use disorder Diabetes and 60% Kidney disorders endocrine diseases 50% Other Tuberculosis & noncommunicable HIV/AIDS 40% diseases Other Infectious Maternal 30% diseases Suicide and 20% Transports & interpersonal unintentional injuries violence 10% Not elsewhere classifiable 0% Male (n=134) Female (n=96) The proportion of deaths due to cardiovascular diseases increased across the age groups whereas the proportion of deaths due to suicide and transport injuries was higher among the younger age group (15-29 years). The proportion of deaths due to neoplasm was highest among 45-59 years age group. Deaths due to tuberculosis, the proportion was higher among 30-44 years age group (Figure 6). 36 | P a g e Figure 6: Distribution of deaths according to age category, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) 100% Cardiovascular Neoplasm diseases 90% Chronic respiratory Digestive diseases 80% diseases 70% Neurological Mental and substance disorders use disorder 60% 50% Diabetes and Kidney disorders endocrine diseases 40% Other Tuberculosis & noncommunicable 30% HIV/AIDS diseases 20% Other Infectious Maternal diseases 10% Suicide and Transports & 0% interpersonal unintentional injuries 15-29 years30-44 years45-59 years 60 years & violence (n=22) (n=24) (n=37) above (n=147) Not elsewhere classifiable 5.10. Neonatal Deaths (0 days to 28 days) We have found 13 neonatal deaths in which eight were males and five were females. Birth asphyxia accounted for six deaths followed by three deaths due to stillbirth (Annexure part B – table 13). The most common place of neonatal deaths were PHC/CHC/Rural hospital (5) followed by district hospital (4) and private hospital (2) whereas two deaths occurred at home (Annexure part B - table 14). 5.11. Child Deaths (29 days to 14 years) Overall, 10 child deaths were surveyed, three were males and seven were females. Overall 60% of children were under five years of age whereas 40% of children were above 6 years of age. In the broad category of diseases of the blood and certain disorders involving the immune mechanism which includes three deaths caused due sickle cell anaemia (1), acquired hemolytic anaemia (1) and thalassemia (1) followed by two deaths due to diarrhea. 37 | P a g e In the category of neurological diseases, cerebral palsy (1) and epilepsy (1) were killers. Pneumonia (1), the toxic effect of venom (1) and ill-defined (1) were other causes of death in children of the study population (Annexure part B - table 15). Most of the child deaths were occurred at home (4) followed by district hospital (3), PHC/CHC/Rural hospital (2) and private hospital (1) (Annexure part B - table 16). 38 | P a g e 6. Discussions A relatively limited data set available on the health conditions, disease profile and cause of death of the tribal groups across the country shows that disease affecting tribal population vary from state to state and area to area and even within a state, depending on the environmental and social conditions, availability of employment and cultural practices prevalent in tribal areas. Starting with exploration and discussion with anthropometric aspects, we also found the prevalence of underweight (< -2SD) among children under 5 years of age was 42.7%, stunting (32.8%) and wasting was 14.1%. This was much higher than the NHFS-4 survey of Chhattisgarh, where prevalence of underweight (< -2SD) among children under 5 years of age was 39.6%. However stunting (< -2SD) was 39.2% and wasting (< -2SD) was 23.7%.15 There were much lower than NHFH-4 reported data of Chhattisgarh, However these were much lower as compared to NNMB tribal data (2009). This improvement could be due to improvement in the ICDS program over the years. We also observed the prevalence of underweight (BMI<18.5 kg/m2) among women was 31.7% and 29% in men in Tamnar Block. This is much higher than the NFHS-4 India survey where the prevalence of underweight among women was 26.7% and 23 % among men residing in the rural parts of India15. However, this is much less than the NNMB 2009 tribal survey of MP and C.G. This improvement could be due to improved Public Distribution System (PDS). During the survey, the prevalence of overweight and obesity (BMI >25kg/m2) was 14.7% among females and 13.6% among males. This is similar to NFHS-4 rural India data5. In our study prevalence of anaemia among non-pregnant non-lactating (NPNL) women was 64.8%. The prevalence of anaemia among pregnant women was 58.1%. This is higher than NFHS-4 India, as well as Chhattisgarh data where anaemia was 48.5% among non-pregnant women and 43.6% among pregnant women15. Another study done by Chakma et al. (2014) among Baiga tribe of Madhya Pradesh reported the prevalence of moderate anaemia among non-pregnant women was 60.6% and 7.3% with severe anaemia.6 In our study the prevalence of severe anaemia was only 1.8% among non-pregnant non -lactating (NPNL) women and 2.3% among pregnant women. Again the low prevalence could be due to improved Public Distribution system (PDS). 39 | P a g e During the survey (2019), we found 19 patients were suffering from Pulmonary Tuberculosis (13 already on ATT and 6 were identified through sputum examination among suspected individuals by our team. As we have covered 5233 population (from 984 households) which includes all the family members of the households. Thus the TB burden among the study population was 363/100,000 population which is above the national rate (2018) of 199/100,000 and TB Patients Notification rate of Chhattisgarh 103/100,000 (2018)17. Asystematic review & meta-analysis done by Beena et al. (2015), the overall burden of tuberculosis was 703/100,000 populations among the tribal population18. These unreported or undiagnosed cases found during the survey could be due to poor outreach of RNTCP and shortage of staff. Fungal infection in the skin diagnosed clinically by a Medical Officer seen in 4.0% of all the adult participants, more in males (49%) than females (51%). Various causes such as environment, overcrowding, diabetes mellitus, bathing in contaminated water and poor living conditions may be major factors. A report by CSIR-NEERI (2018), supports this hypothesis as the presence of alarmingly high levels of Arsenic in drinking water along with acidic pH of water in 14 villages of Tamnar block20 and the optimal pH for arsenic absorption is 5.0 were associated with the development of fungal infection among villagers21. The study by Hsu et al. (2018), also shows cumulative arsenic exposure is associated with fungal infections22. During the survey, we also observed high prevalence of acute respiratory infection (ARI) (20.9%)This was much higher than the NFHS-4 Chhattisgarh report where it was only 2.2 % in the last 2 weeks preceding the survey.15, 16 The reason could be due to environmental pollution or poor air quality index. However, in-depth studies need to be done to rule out possible other causes of infections as any infection of the lung in early childhood may cause the development of COPD and bronchiectasis in later years of life27. The prevalence of diarrhoea was only 2.4% among pre-school children during the survey. This is much lower than the NFHS-4 Chhattisgarh data where the prevalence of diarrhoea (reported) was 8.6%15. The low prevalence of diarrhoea could be improved in sanitation and hygiene as more than 91% households have sanitary latrines and more than 73% households drinking water is though community pipe water or hand pump. We also observer the overall prevalence of hypertension among females was 17.7% and 33.9% among males. This is much higher than the NFHS-4 Chhattisgarh data where it was 40 | P a g e only 9% among females and 10.9% in males15. IDSP data (2007-08), also reported the prevalence of hypertension was 21% among adults in Madhya Pradesh25. NNMB (2009), reported prevalence of hypertension was 25% in males and 23% in females23. Chakma et al. (2017) reported the overall prevalence of hypertension was 26% whereas 19% of hypertension was found among low BMI individuals26 among tribals of Mandla, Madhya Pradesh which is similar to our observation. United Nations Environment Programme, the International Labour Organization, and the World Health Organization, also suggested a causal relationship between arsenic exposure and the development of hypertension and cardiovascular disease24. However, in-depth studies are essential to identify all the risk factors associated with hypertension and cardiovascular diseases. Out of 49 children evaluated for the history of immunization, 77.5% children were fully immunized and only 2.0% of children were not immunized. Overall BCG vaccine coverage was 97.96%, DPT coverage was 83.6% and OPV 3 vaccination coverage was 79.5. The Measles vaccination coverage in the present study was 91.8% & overall vitamin A first dose was received by 87.7% children. In comparison with NFHS-4 data, coverage of fully immunized children was more than national average15. Mortality data are important for planning evidence-based intervention strategy. Globally non-communicable diseases are the leading causes of death, the overall 41 million people died each year almost equivalent to 71% of all deaths globally30. The present study showed the overall 53.9 % of deaths due to non-communicable diseases; which is similar to WHO report, of deaths due to NCDs (53%). Among NCDs, a higher proportion of deaths due to cardiovascular diseases accounted for 34.3% of total deaths in Tamnar block which is higher than the proportion of deaths due to cardiovascular diseases (27%) stated by WHO.29 According to a report submitted by the economic forum and Howard School of public health says cardiovascular diseases are prevalent NCDs in India31 whereas this study also finds similar findings. In Tamnar block, Cancer deaths were attributed to 4.7% of total deaths which is comparatively less than the proportion of cancer deaths (9%) in India (WHO report).29 Among cancers, this study found a majority of the deaths attributed to digestive organ cancer; accounted for 2.2% of total deaths. This could be due to more alcohol intake. As alcohol consumption is a part of tribal culture and it is socially accepted among tribal communities which corroborates from the history that three-third of the deceased (33.9%) had a history of alcohol consumption in the last five years. 41 | P a g e Every year most of the people die due to suicide, almost one million deaths attributed to suicide.32 India ranks 43rd in descending order of rates of suicide (10.6/100000) reported in 2009 (WHO suicide rates).33 According to NCRB (National Crime Record Bureau) report, in India, every year more than 1,00,000 people commit suicide. In Tamnar block, this study found 4.3% of total deaths due to suicide whereas Chhattisgarh contributed 4.9% of deaths,35 nearly equal proportion to this study. An Indian study showed that the suicide rate was highest among the younger age group (15-29 years) (38/100000 population).34 Similar finding was found in this study. The overall proportion of deaths due to suicide (22.7%) was higher among 15-29 years age group. The National Crime Record Bureau also reported a similar pattern in the 2017 report.35 This study contributed to more deaths due to accidental and unintentional injuries including road traffic accidents, overall 7.8% of deaths accounted due to accidents and injuries; the reason could be the history of higher alcohol intake among the deceased and may be high traffic generations due to mining activities. 42 | P a g e 7. Conclusions Fever and ARI were the major morbidities among villagers of Tamnar Block. Anaemia prevalence was about 64.8% among non-pregnant non-lactating women. Prevalence of hypertension was about 21.8%. Fungal Infection (4.0%) was a common problem among > 15 years of age of Tamnar Block. Sputum positive Tuberculosis was higher than the National average in Tamnar Block. The prevalence of skeletal fluorosis was about 1.1% among age > 15 years of age. Most of the cases were from Mudagaon and Saraitola at the time of the survey. The prevalence of severe malnutrition was 16.9% among <5 years children. Non-communicable diseases were the leading cause of death. Among NCDs, a majority of the deaths occurred due to cardiovascular diseases and the proportion of deaths due to CVD was higher among the older age group. Hypertension was the leading pre-existing disease and diabetes and stroke were the second and third leading pre-existing diseases. Among infectious diseases, tuberculosis was the leading cause of death. Alcohol liver diseases caused the majority of deaths in the category of digestive system diseases; proportion being higher among males as compared to females. Among external causes, the proportion of deaths due to suicide were higher among males as compared to females; proportion being higher among the younger age group (15-29 years). Road Traffic Accident (RTA) was found higher among the younger age group (15- 29 years). 43 | P a g e 8. Recommendations Considering the high prevalence of anaemia. Anaemia Prophylaxis programme should be strengthened. Vacant post of specialist doctors and trained health workers should be filled as per IPHS guideline. Provision for safe drinking water especially in two villages Mudagaon and Saraitola (i.e. fluoride free, arsenic free or other geogenic contamination). Strengthening of laboratory facilities in CHC and PHC in Tamnar Block. Intervention programmes for Non-communicable disease specially for hypertension and other cardiovascular diseases should be undertaken in Tamnar. RNTCP program at the block level should be strengthened for early case detection, initiation of treatment and better compliance to reduce the mortality due to tuberculosis. Provision of “TrueNat test” for rapid diagnosis of tuberculosis at CHC Tamnar. Integrated Child Development Services (ICDS) program need to be strengthened and special nutrition supplementation program should be implemented to reduce the stunting and wasting of <5 year children. Multisectoral collaboration should be initiated to develop a suicide prevention strategy like decriminalizing suicide attempts and training more counsellors and psychologist to help those battling with depression and other mental problems. A collective effort has to be needed from all stakeholder including immediate family members, public health planners, policymakers and NGOs to prevent suicides. In-depth epidemiological studies required to study the various risk factors for hypertension and other cardiovascular diseases should be undertaken. 44 | P a g e 9. References 1. Statistical profile of scheduled tribes in India India, 2013. Ministry of Tribal Affairs Statistics Division Government of India. Available from:https://tribal.nic.in/ST/StatisticalProfileofSTs2013.pdf. Accessed on 5.1.2020 2. Highlights D. The Scheduled Tribes.CG: Office of the Registrar General, India, Census of India. 2001:1-4. Accessed on 5.1.2020 3. Census of India (2011): Series - 23 Part- Xii-A District Census Handbook Raigarh Village & Town Directory Directorate of Census Operations Chhattisgarh. Available from: http://censusindia.gov.in/2011census/dchb/DCHB_A/22/2204_PART_A_DCHB_R AIGARH.pdf. Accessed on 5.1.2020 4. Raigarh District Available from https://raigarh.gov.in/en/. Accessed on 5.1.2020 5. Increased health problems and diminishing forests: how coal mining in Chhattisgarh spells disaster: Author/Blogger: Makarand Purohit posted on 17th May 2017. Available from: https://yourstory.com/2017/05/coal-mining-chhattisgarh/. Accessed on 5.1.2020. 6. Chakma T, Meshram P, Kavishwar A, Vinay Rao P, Rakesh Babu (2014) Nutritional Status of Baiga Tribe of Baihar, District Balaghat, Madhya Pradesh. J Nutr Food Sci 4: 275. doi: 10.4172/2155-9600.1000275.Accessed on 5.1.2020 7. Aziz N, Kallur SD, Nirmalan PK. Implications of the revised consensus body mass indices for Asian Indians on clinical obstetric practice. Journal of clinical and diagnostic research: JCDR. 2014 May;8(5):OC01. Accessed on 5.1.2020 8. James WP, Ferro-Luzzi A, Waterlow JC. Definition of chronic energy deficiency in adults. Report of a working party of the International Dietary Energy Consultative Group. European journal of clinical nutrition. 1988 Dec;42(12):969-81.Accessed on 5.1.2020 9. American Diabetes Association. 2. Classification and diagnosis of diabetes. Diabetes care. 2017 Jan 1;40 (Supplement 1):S11-24.Accessed on 5.1.2020 10. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. World Health Organization; 2011.Accessed on 5.1.2020 45 | P a g e 11. National High Blood Pressure Education Program. Classification of Blood Pressure- The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. 2004.Accessed on 5-1-2020. 12. Standard I. Drinking water-specification. 1st Revision, IS. 1991;10500. Accessed on 5-1-2020. 13. SRS Collaborators of the RGI-CGHR. Prospective study of million deaths in India: technical document no VIII: health care professional’s manual for assigning causes of death based on RHIME reports. 2011. Accessed on 5.1.2020 14. International Disease Classification Available from: https://www.icd10data.com/ICD10CM/Codes Accessed on 5.1.2020 15. National Family Health Survey (NFHS-4). Available from: http://rchiips.org/NFHS/NFHS-4Reports/India.pdf. Accessed on 24.01.2020 16. Dhirar N, Dudeja S, Khandekar J, Bachani D. Childhood Morbidity and Mortality in India—Analysis of National Family Health Survey 4 (NFHS-4) Findings. Indian pediatrics. 2018 Apr 1;55(4):335-8. Accessed on 24.01.2020 17. TB Statistics India. Available from: https://tbfacts.org/tb-statistics-india/. Accessed on 24.01.2020 18. Thomas BE, Adinarayanan S, Manogaran C, Swaminathan S. Pulmonary tuberculosis among tribals in India: A systematic review & meta-analysis. The Indian journal of medical research. 2015 May;141(5):614. Accessed on 24.01.2020 19. Rao PN, Suneetha S. Current situation of leprosy in India and its future implications. Indian dermatology online journal. 2018 Mar;9(2):83. Accessed on 24.01.2020 20. Investigation on water sources in 14 villages of Tamnar Block of Raigarh District, Chhattisgarh: CSIR-NEERI, Nagpur: 2018. 21. Ratnaike RN. Acute and chronic arsenic toxicity. Postgraduate medical journal. 2003 Jul 1;79(933):391-6. Accessed on 2.2.2020 22. Hsu LI, Cheng YW, Chen CJ, Wu MM, Hsu KH, Chiou HY, Lee CH. Cumulative arsenic exposure is associated with fungal infections: Two cohort studies based on southwestern and northeastern basins in Taiwan. Environment international. 2016 46 | P a g e Nov 1;96:173-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27693976. Accessed on 2.2.2020 23. Diet and Nutritional status of Tribal Population and Prevalence of Hypertension among Adults: National Nutrition Monitoring Bureau: Report 25, 2009: National Institute of Nutrition (ICMR), Hyderabad. Accessed on 24.01.2020. 24. Gomez-Caminero A, Howe PD, Hughes M, Kenyon E, Lewis DR, Moore M, Aitio A, Becking GC, Ng J. Arsenic and arsenic compounds. World Health Organization; 2001. Accessed on 24.01.2020. 25. Non-communicable Disease Risk Factor Survey: Integrated Disease Surveillance Project: Madhya Pradesh: 2009. Accessed on 24.01.2020 26. Chakma T, Kavishwar A, Sharma RK, Rao PV. High prevalence of hypertension and its selected risk factors among adult tribal population in Central India. Pathogens and global health. 2017 Oct 3;111(7):343-50. Accessed on 24.01.2020 27. The LR. Fuelling advances in paediatric lung health. The Lancet. Respiratory medicine. 2020 Jan 22. Available from: https://www.thelancet.com/action /showPdf?pii=S2213-2600%2820%2930015-1. Accessed on 2.2.2020 28. K. Balachand: You will be on BPL list if your annual income is Rs. 27,000. The Hindu. Available from: https://www.thehindu.com/news/national/you-will-be-on- bpl-list-if-your-annual-income-is-rs27000/article2035893.ece. Accessed on 2.2.2020 29. World health organization. NCD country profiles. 2016. Available from: https://www.who.int/nmh/countries/ind_en.pdf?ua=1.Accessed on 14.02.2020 30. World Health Organization. Fact sheet, noncommunicable diseases, key facts. Available from: https://www.who.int/news-room/fact- sheets/detail/noncommunicable-diseases.Accessed on 14.02.2020 31. Economics of Non-Communicable Diseases in India A report by the World Economic Forum and the Harvard School of Public Health. Available from: http://www3.weforum.org/docs/WEF_EconomicNonCommunicableDiseasesIndia_ Report_2014.pdf.Accessed on 14.02.2020 32. World Health Organization. Mental health. Suicide data. Available from:https://www.who.int/mental_health/prevention/suicide/suicideprevent/en/. Accessed on 14.02.2020 47 | P a g e 33. Radhakrishnan R, Andrade C. Suicide: An Indian perspective. Indian J Psychiatry. 2012 Oct;54(4):304-19. doi: 10.4103/0019-5545.104793. PMID: 23372232; PMCID: PMC3554961. 34. G. Gururaj, M.K. Isaac, D.K. Subbakrishna& R. Ranjani (2004) Risk factors for completed suicides: a case–control study from Bangalore, India, Injury Control and Safety Promotion, 11:3, 183-191, DOI: 10.1080/156609704/233/289706 35. Accidental Deaths and Suicides in India, 2017. Available from: http://ncrb.gov.in/StatPublications/ADSI/ADSI2017/chapter-2%20suicides.pdf. Accessed on 14.02.2020 48 | P a g e 10. Annexures Part-A: Tables and Figures (Health Assessment of villagers) Table 1: Distribution of socio-demographic factors of villagers of the Tamnar Block, Raigarh C.G. 2019 Category Factor n (%) Overall Age 0-14 yrs 1872 35.8 in Years (n=5233) 15-59 yrs 3021 57.7 ≥ 60 yrs 340 6.5 Gender (n=5233) Male 2530 48.3 Female 2703 51.6 Age in Years(n=1713) 0-5 yrs 415 24.2 6-14 yrs 390 22.8 15-24 yrs 119 6.9 25-44 yrs 633 37.0 45-64 yrs 128 7.5 65 yrs and above 28 1.6 Gender (n=1713) Male 655 38.3 Female 1058 61.7 Type of House (n=984) Kuchcha 594 60.4 Semi-Pucca 313 31.8 Pucca 77 7.8 Religion of the Head of the Hindu 979 99.5 Household Muslim 1 0.1 (n=984) Christian 4 0.4 Caste of Head of the Scheduled Tribes 495 50.3 Household Scheduled Caste 161 16.4 (n=984) OBC 305 30.9 General 23 2.4 Type of Family (n=984) Nuclear 574 58.3 Joint 410 41.7 49 | P a g e Family economic status Below Poverty Line 68 7.5 (n=905) Above Poverty Line 837 92.5 Marital status (n=5233) Married 2708 51.7 Unmarried 593 11.3 Widower 199 3.8 Separated 5 .1 Not applicable for 1728 33.0 children < 5yrs Literacy Status Illiterate 303 5.8 (n=5233) Can only sign 422 8.1 Can read & write 16 .3 Primary 1282 24.5 Middle 1119 21.4 High School 695 13.3 Secondary 411 7.9 Graduate 179 3.4 Postgraduate 48 .9 Not applicable for 758 14.5 children < 5years Occupation of the Household Unemployed 217 4.1 (n=5233) Government employee 120 2.3 Private employee 398 7.6 Business owner 92 1.8 Farmer 724 13.8 Daily wage earner 403 7.7 Pensioner 15 0.3 Housewife 1075 20.5 Student 1298 24.8 Not applicable for 891 17 children < 5years Source of Drinking water Open well 225 22.9 (n=984) Tube well 109 11.2 50 | P a g e Community Water 603 61.2 Supply 20 2.0 Individual tap 15 1.5 Hand Pump 10 1.0 RO Plant 2 0.2 Filter/Pack water Source of water used for Open well 224 13.1 bathing (n=1713) Tube well 151 8.8 Community water supply 293 17.1 Individual tap 15 0.9 Hand pump 7 0.4 Stream/ River 65 3.8 Pond 956 55.8 others 2 0.1 Other features (n=984) Sanitary Latrine 897 91.1 Electrification 983 99.8 Fuel used for cooking Firewood 813 82.6 Coal 34 3.5 Cow dung 19 1.9 Electricity 33 3.4 Gas 85 8.6 Smoking habit (n=905) No 821 90.7 Yes 84 9.3 Male (n=84) 78 92.8 Female (n=84) 6 7.2 Alcohol use (n=905) No 825 91.2 Yes 80 8.8 Male (n=80) 42 52.5 Female (n=80) 38 47.5 51 | P a g e Table 2: Age and sex distribution of the study population at Tamnar Block, Raigarh, C.G. (n=5233) Age Category Male Female Total n (%) n (%) n (%) 0-4 343 299 642 (13.6) (11.1) (12.3) 5-9 335 368 703 (13.2) (13.6) (13.4) 10-14 226 301 527 (8.9) (11.1) (10.1) 15-19 105 193 298 (4.2) (7.1) (5.7) 20-29 363 556 919 (14.3) (20.6) (17.6) 30-39 531 443 974 (21.0) (16.4) (18.6) 40-49 241 197 438 (9.5) (7.3) (8.4) 50-59 190 202 392 (7.5) (7.5) (7.5) 60-69 145 104 249 (5.7) (3.8) (4.8) >70 51 40 91 (2.0) (1.5) (1.7) Total 2530 2703 5233 (100) (100) (100) - Table 3: Prevalence of major morbidities among pre-school children of Tamnar Block, Raigarh, C.G., 2019 (n= 415) General Morbidities (n= 415) n % Fever 26 6.2 Diarrhoea&Dysentry 10 2.4 Acute respiratory infection 87 20.9 Scabies 7 1.6 Anaemia (clinically diagnosed) 11 2.6 Fungal Infection (clinically diagnosed) 5 1.2 Lymph Node Enlargement 2 0.4 52 | P a g e Cerebral Palsy 3 0.7 History of Worm Infestation 6 1.4 Others including Mental illness 23 5.5 Table 4: Prevalence of major nutritional deficiency disorder among pre-school children of Tamnar Block, Raigarh, C.G., 2019 Nutritional Deficiency Disorders (n= 415) n % Hair Spares 9 2.1 Hair Discolored 7 1.6 Emaciation 4 0.9 Marasmus 5 1.2 Knock knee 24 5.7 Night Blindness 1 0.2 Angular stomatitis 2 0.4 NAD 370 76.3 Table 5: Prevalence of major morbidities among school going childrens (6-14 yrs) of Tamnar Block, Raigarh, C.G. 2019 General Morbidities ( n=390) n % Fever 18 4.6 Diarrhoea 3 0.7 Acute respiratory infection 55 14.1 Dental fluorosis 21 5.3 Anaemia (clinically diagnosed) 26 6.6 History of worm infestation 10 2.5 Fungal Infection (clinically diagnosed) 9 2.3 leprosy 1 0.2 Skeletal fluorosis 1 0.2 Cerebral Palsy 1 0.2 Lymph Node Enlargement 2 0.5 Other including Scabies, Sickel cell Anaemia, Otitis 14 3.5 Media, Mental Illness 53 | P a g e Table 6: Prevalence of nutritional deficiency disorder among School going childrens (6- 14 yrs) of Tamnar Block, Raigarh, C.G. 2019 Nutritional Deficiency Disorders (n=390) n % Emaciation 11 2.8 Marasmus 1 0.2 Bitot’s Spot 2 0.5 Angular stomatitis 1 0.2 Knock Knee 31 7.9 Bow legs 2 0.5 Dental caries 12 3.0 NAD 331 84.8 Table 7: Prevalence of major morbidities among villagers (Age > 15yrs) of Tamnar Block, Raigarh, C.G. 2019 General Morbidities ( n=908) n % Fever 24 2.6 Diarrhoea&Dysentry 8 0.8 Acute respiratory infection (ARI) 33 3.6 Scabies 11 1.2 Dental fluorosis 3 0.3 Anaemia (clinically diagnosed) 147 16.1 Asthma/Bronchitis/COPD 4 0.4 Hypertension 198 21.8 Ischemic Heart Disease (IHD) 9 0.9 Arthritis 10 1.1 Road Traffic Accident (RTA) 8 0.8 STD 2 0.2 HIV 1 0.1 Diabetes 26 2.8 Fungal Infection (clinically diagnosed) 37 4.0 Skeletal Fluorosis 10 1.1 Filariasis 3 0.3 Others ( Including Urinary Tract Infection (UTI), Cataract, 84 9.2 Asthma/Bronchitis/COPD, Multiple Boils, etc) NAD 455 50.1 - 54 | P a g e Table 8: Prevalence of nutritional deficiency disorder among villagers (Age > 15yrs) of Tamnar Block, Raigarh, C.G. 2019 Nutritional Deficiency Disorders (n=908) n % Hair Spares 6 0.6 Moon Face 3 0.3 Emaciation 39 4.2 Knock knee 3 0.3 Bow leg 3 0.3 Goiter 2 0.2 NAD 839 92 Table 9: Gender-wise distribution of systolic blood pressure according to (JNC VII Classification) Tamnar Block, Raigarh, C.G.2019 (n= 905) Grades of Hypertension Male Female Total Number (%) Number (%) Number (%) Normal 84 (36.5) 370 (54.8) 454 (50.2) (<120 mmHg) Pre Hypertension 92 (40) 246 (36.4) 338 (37.3) (120-139 mmHg) Stage I & II Hypertension 54 (23.5) 59 (8.8) 113 (12.5) (>140 mmHg) Total 230 (100) 675 (100) 905 (100) Table 10: Gender-wise distribution of diastolic blood pressure according to (JNC VII Classification) Tamnar Block, Raigarh, C.G.2019 (n= 905) Grades of Hypertension Male Female Total Number (%) Number (%) Number (%) Normal 90 (39.1) 340 (50.4) 430 (47.5) (<80 mmHg) Pre Hypertension 77 (33.4) 236 (35.0) 313 (34.6) (80-89 mmHg) Stage I& II Hypertension 63 (27.4) 99 (14.7) 162 (17.9) (>90 mmHg) Total 230 (100) 675 (100) 905 (100) 55 | P a g e Table 11: Age group-wise distribution of systolic blood pressure among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 905) Age Category Systolic Blood Pressure Total Normal Pre HTN Stage-I Stage-II n% n % n% HTN HTN n% n% <20 6 2 1 0 9 (1.3) (0.6) (1.2) (0.0) (1.0) 20-29 225 112 7 1 345 (49.6) (33.1) (8.6) (3.1) (38.1) 30-39 153 138 26 7 324 (33.7) (40.8) (32.1) (21.9) (35.8) 40-49 43 47 20 9 119 (9.5) (13.9) (24.7) (28.1) (13.1) 50-59 17 18 17 5 57 (3.7) (5.3) (21.0) (15.6) (6.3) 60-69 7 17 8 6 38 (1.5) (5.0) (9.9) (18.8) (4.2) >70 3 4 2 4 13 (0.7) (1.2) (2.5) (12.5) (1.4) - Figure 1: Age group-wise distribution of systolic blood pressure among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 905) >70 0.7 1.2 2.5 12.5 60-69 1.5 5.0 9.9 18.8 50-59 3.7 5.3 21.0 15.6 40-49 9.5 13.9 24.7 28.1 30-39 33.7 40.8 32.1 21.9 20-29 49.6 33.1 8.6 3.1 <20 1.3 0.6 1.2 0.0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Normal Pre Hypertensive Stage I Stage II Percentage 56 | P a g e Table 12: Age group-wise distribution of diastolic blood pressure among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 905) Age category Diastolic Blood Pressure Total Normal Pre HTN Stage-I Stage-II n % n % n % HTN HTN n % n % <20 7 1 1 0 9 (1.6) (0.3) (0.9) (0.0) (1.0) 20-29 204 113 26 2 345 (47.4) (36.1) (22.8) (4.2) (38.1) 30-39 146 118 45 15 324 (34.0) (37.7) (39.5) (31.3) (35.8) 40-49 35 45 21 18 119 (8.1) (14.4) (18.4) (37.5) (13.1) 50-59 22 17 12 6 57 (5.1) (5.4) (10.5) (12.5) (6.3) 60-69 12 13 7 6 38 (2.8) (4.2) (6.1) (12.5) (4.2) >70 4 6 2 1 13 (0.9) (1.9) (1.8) (2.1) (1.4) Figure 2: Age group-wise distribution of diastolic blood pressure among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 905) >70 0.9 1.9 1.8 2.1 60-69 2.8 4.2 6.1 12.5 50-59 5.1 5.4 10.5 12.5 40-49 8.1 14.4 18.4 37.5 30-39 34.0 37.7 39.5 31.3 20-29 47.4 36.1 22.8 4.2 <20 1.6 0.3 0.9 0.0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Normal Pre Hypertensive Stage I stage II Percentage 57 | P a g e Table 13: Percentage distribution of systolic blood pressure according to body mass index (BMI) among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 899) Systolic Blood Pressure Pre Stage-I Stage-II BMI Normal HTN HTN HTN Total Underweight 187 74 14 3 278 67.3% 26.6% 5.0% 1.1% 100.0% Normal 233 195 51 12 491 47.5% 39.7% 10.4% 2.4% 100.0% Overweight 28 56 10 12 106 26.4% 52.8% 9.4% 11.3% 100.0% Obese 4 11 5 4 24 16.7% 45.8% 20.8% 16.7% 100.0% Table 14: Percentage distribution of diastolic blood pressure according to body mass index (BMI) among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 899) Diastolic Blood Pressure Normal Pre Stage-I Stage-II BMI HTN HTN HTN Total Underweight 171 76 24 7 278 61.5% 27.3% 8.6% 2.5% 100.0% Normal 224 175 68 24 491 45.6% 35.6% 13.8% 4.9% 100.0% Overweight 30 49 13 14 106 28.3% 46.2% 12.3% 13.2% 100.0% Obese 4 10 7 3 24 16.7% 41.7% 29.2% 12.5% 100.0% Table 15: Percentage distribution of systolic blood pressure according to income status among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 905) Systolic Blood Pressure Family Pre Stage-I Stage-II status Normal HTN HTN HTN Total BPL 41 20 6 1 68 60.3% 29.4% 8.8% 1.5% 100.0% APL 413 318 75 31 837 49.3% 38.0% 9.0% 3.7% 100.0% Total 454 338 81 32 905 50.2% 37.3% 9.0% 3.5% 100.0% 58 | P a g e Table 16: Percentage distribution of systolic blood pressure according to income status among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 905) Diastolic Blood Pressure Pre Stage-I Stage-II Family Status Normal HTN HTN HTN Total BPL 40 18 9 1 68 58.8% 26.5% 13.2% 1.5% 100.0% APL 390 295 105 47 837 46.6% 35.2% 12.5% 5.6% 100.0% Total 430 313 114 48 905 47.5% 34.6% 12.6% 5.3% 100.0% Table 17: Distribution of hemoglobin level according to age category among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 149) Age Category Haemoglobin level Male Female Total n (%) n (%) 6-59 months Non-Anaemia 13 (50.0) 22 (61.1) 35 (56.5) (n=62) (> 11.0 g/dL) Mild 6(23.1) 6 (16.7) 12 (19.4) (10.0-10.9 g/dL) Moderate 6 (23.1) 7 (19.4) 13 (20.9) (7.0-9.9 g/dL) Severe 1 (3.8) 1 (2.8) 2 (3.2) (<7 g/dL) Total 26 (100) 36 (100) 62 (100) 6-14 yrs Non-Anaemia 20 (52.6) 20 (40.8) 40 (46.0) (n=87) (> 12.0g/dL) Mild 9 (23.7) 16 (32.7) 25 (28.7) (10g/dL-11.9g/dL) Moderate 8 (21.1) 13 (26.5) 21 (24.1) (7.0-9.9g/dL) Severe 1 (2.6) 0 (0) 1 (1.2) (<7g/dL) Total 38 (100) 49 (100) 87 (100) 59 | P a g e Figure 3: Percentage distribution of anaemia among women (above 15 years of age) in Tamnar Block, Raigarh C.G. 2019 (n= 222) Severe (< 7 g/dL) 1.8 Moderate (7-10 g/dL) 30.6 Mild (10.0-12.0 g/dL) 32.4 Non-anaemic (> 12.0 g/dL) 35.5 0 5 10 15 20 25 30 35 40 Percentage Table 18: Percentage distribution of anaemia according to hemoglobin level among pregnant women in Tamnar Block, Raigarh, C.G. 2019 (n= 43) Grades of Anaemia Number (%) Non-anaemia 11-12.99 g/dl 18 (41.9) Mild 9.00-10.99 g/dl 15 (34.9) Moderate 7.00-8.99 g/dl 9 (20.9) Severe < 7 g/dl 1 (2.3) Total 43 Table 19: Percentage distribution of worm infestations in school going children of Tamnar Block, Raigarh, C.G. 2019 (n= 267) Type of Infestation Number % Round Worm 29 10.9 Hookworm 8 2.9 Thread worm 3 1.1 Round Worm with Entamoebacoli 3 1.1 Entamoeba Coli 46 17.3 Negative Test 178 66.7 - 60 | P a g e Table 20:Gender-wisepercentage distribution of BMI as per James et al. classification among the villagers of Tamnar Block, Raigarh, C.G. 2019 (n= 897) (Age >18 Years) BMI Male Female Total < 16 CED III Degree 20 44 64 8.8% 6.6% 7.1% 16-17 CED II Degree 16 64 80 7.0% 9.6% 8.9% 17-18.5 CED I Degree 30 104 134 13.2% 15.5% 14.9% 18.5-20 Low Normal 38 111 149 16.7% 16.6% 16.6% 20-25 Normal 93 248 341 40.8% 37.1% 38.0% 25-30 Over Weight I 25 80 105 11.0% 12.0% 11.7% > 30 Over Weight II 6 18 24 2.6% 2.7% 2.7% Total 228 669 897 *CED- Chronic Energy Deficiency Table 21:Percentage distribution of children according to SD Classification in Tamnar Block, Raigarh, C.G. 2019 Variables < - -3SD TO - -2SD TO -1SD TO >MEDIAN 3SD 2SD -1SD MEDIAN Weight for Age 53 121 156 63 21 (n= 414) 12.8 29.9 37.7 15.2 5.1 Height for Age 54 78 113 98 59 (n=402) 13.4 19.4 28.1 24.4 14.7 *Weight for Height 9 27 129 70 20 (n=255) 3.5 10.6 50.6 27.5 7.8 *upto 59 months 61 | P a g e Table 22: Status of immunization coverage among children upto 5 years, Tamnar Block, Raigarh, C.G. 2019 (n= 415) Vaccine n % BCG (n=415) 399 96.1 DPT (n=414) 397 95.8 OPV(n=415) 396 95.4 Measles (n=411) 385 93.6 Vit. A(n=411) 381 92.7 Table 23: Distribution of immunization status among Child of 12-23 months in Tamnar Block, Raigarh, C.G. 2019 Child Immunization of 12-23 months as compared to NFHS-4 Data Indicator Tamnar (%) India- Rural (%) Children 12-23 months fully immunized 77.55 61.3 Children 12-23 months not received any vaccination 2.04 Children 12-23 months who have received BCG 97.96 91.4 Children 12-23 months who received three doses of DPT 83.67 77.7 Children 12-23 months who received three doses of polio 79.59 72.6 Children 12-23 months who have received measles 91.84 80.3 Children (age 9 month and above) received at least one dose of 87.76 59.1 vitamin-A Table 24: Distribution of health services utilization: Antenatal care in Tamnar Block, Raigarh, C.G. 2019 (n= 74) Type of Services n (%) TT Injection 64 (86.4) Ironic Folic Acid supplement 67 (90.5) Frequent Check up 73 (98.6) ANM 16 (21.9) AWW 31 (36.9) PHC 8 (10.9) SubCenter 16 (21.9) 62 | P a g e Private Doctor 2 (2.7) Supplementary Food FromAaganwadi 65 (87.8) Table 25: Distribution of iron folic acid tablet supplementation in Tamnar Block, Raigarh, C.G. 2019 (n= 67) Total Number of tablet n (%) <50 31 (46.3) 50-80 22 (32.8) >80 14 (20.9) Table 26: Distribution of health services utilization: Postnatal care in Tamnar Block, Raigarh, C.G. 2019 (n= 324) Type of Services n (%) Place of Delivery Home 39 (12.0) Govt. Hospital 251 (77.5) Private Hospital 34 (10.5) Table 27: Distribution of households aware of Government Health program facilities in Tamnar Block, Raigarh, C.G. 2019 (n= 984) Type of facility availed n (%) BetiBacchaoBetiPadhaoYojna 962 (97.7) Pradhan Mantri SurakshitMatritv Abhiyan 106 (10.7) RashtriyaSwashthayaBimaYojna 772 (78.4) Aayushman Bharat Yojna 848 (86.1) Table 28:Distribution of household availing Pradhan Mantri Ujjwala Yojana in Tamnar Block, Raigarh, C.G. 2019 (n= 165) n (%) LPG Connection Through PMU Yojna 110 (66.6) Did not had LPG connection 30 (18.2) Personal LPG connection 24 (14.5) Both (Personal & Through PMU Yojna) 1(0.6) Refilling of cylinder (n=131) Yes 45(34.3) 63 | P a g e No 86(65.6) Reason for not re-filling of cylinder (n=86) Cost 83(96.6) Cylinder has created problem earlier 3(3.4) Table 29: Percentage distribution of fluoride level in urine samples of villagers in Tamnar Block, Raigarh, C.G. 2019 (n= 30) Fluoride Level in Urine Number Percentage (in PPM) 0.10-2.0 12 40 >2.1 18 60 Total 30 100 Table 30: Percentage distribution of fluoride level (>2.1 PPM) in urine samples of villagers in Tamnar Block, Raigarh, C.G. 2019 (n= 18) Name of Village Flouride level in urine (>2.1 PPM) n % Mudagaon 12 (66.7) Saraitola 5 (27.8) Kodkel 1 (5.6) 64 | P a g e Part-B: Tables & figures (Cause of death) Table 1: Socio-demographic characteristics of adults, Tamnar Block, Raigarh, Chhattisgarh, 2019 (N=230) Sociodemographic characteristics Adults (15 years and above) (n=230) n % Gender Male 134 58.3 Female 96 41.7 Age 15-44 years 46 20 45-69 years 86 37.4 70 years and above 98 42.6 Education Illiterate 139 60.4 1-5 standard 40 17.4 6-12 standard 45 19.6 Graduates 6 2.6 Religion Hindu 229 99.6 Muslim 1 0.4 Community ST 123 53.5 OBC 68 29.6 SC 22 9.6 General 17 7.4 Type of House Kuchcha 175 76.1 Pakka 55 23.9 Availability of BPL card Yes 198 86.1 No 31 13.5 Do not know 1 0.4 Occupation Home maker 72 31.3 Agriculture wage labour 51 22.2 Landlord/Farmer 38 16.5 Unemployed & others 18 7.8 Retired 11 4.8 Student 9 3.9 Unskilled & skilled wage labour 7 3 Professional/Executive 7 3 Government employee 6 2.6 Private employee 6 2.6 Self empoyed 5 2.2 65 | P a g e Table 2: Socio-demographic characteristics of neonates, Tamnar Block, Raigarh, Chhattisgarh, 2019 (n=10) Neonatal (0 days-28 days) (n=13) Sociodemographic characteristics n % Gender Male 8 62 Female 5 39 Age 1 day-28 days 13 100 Place of death PHC/CHC/Rural hospital 5 39 District hospital 4 31 Home 2 15 Private hospital 2 15 Table 3: Socio-demographic characteristics of children, Tamnar Block, Raigarh, Chhattisgarh, 2019 (n=10) Child (29 days-14 years) (n=10) Sociodemographic characteristics n % Gender Male 3 30 Female 7 70 Age 1 month-5 years 6 60 6 Years-14 years 4 40 Place of death Home 4 40 District hospital 3 30 PHC/CHC/Rural hospital 2 20 Private hospital 1 10 66 | P a g e Table 4: Cause of death - associated risk factors, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Categories n % Risk factors Smoking (past 5 years) 62 27 Alcohol consumption (past 5 years) 78 33.9 Smokeless tobacco 88 38.3 Pre-existing diseases Hypertension 69 30 Diabetes 29 12.6 Stroke 19 8.3 Tuberculosis 10 4.3 Chronic respiratory disease 7 3 Heart disease 6 2.6 Cancer 6 2.6 HIV/ AIDS 1 0.4 Place of death (n=230) Home 180 78.3 District hospital 17 7.4 Private hospital 11 4.8 On the way to health facility 8 3.5 Others 6 2.6 PHC/CHC/Rural hospital 4 1.7 Medical collage/ Cancer hospital 4 1.7 Treatment before death PHC/CHC/Rural hospital 56 24.3 Local doctor 45 19.6 Tribal healer 39 17 Private hospital 37 16.1 No treatment 25 10.9 District hospital 24 10.4 Medical college/Cancer hospital 4 1.7 67 | P a g e Table 5: Cause of death among adults according to four major categories as per ICD 10, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Percent of deaths Deaths Categories Adult (15 years & above) Noncommunicable diseases 53.91 (124) Infectious and parasitic diseases 13.91 (32) Injuries & Suicide 12.17 (28) Not elsewhere classifiable 20 (46) Table 6: Distribution of deaths in four major categories by gender, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Male Female Overall Category (n=134) (n=96) (n=230) n % n % n % Noncommunicable diseases 84 62.7 40 41.7 124 53.9 Infectious & parasitic diseases 17 12.7 15 15.6 32 13.9 Injuries & Suicide 16 11.9 12 12.5 28 12.2 Not elsewhere classifiable 17 12.7 29 30.2 46 20 Table 7: Distribution of deaths in four major categories by age category, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Category 15-29 30-44 45-59 60 years & years years years above (n=22) (n=24) (n=37) (n=147) n % n % n % n % Noncommunicable diseases 5 22.7 7 29.2 27 73 85 57.8 Infectious & parasitic diseases 3 13.6 7 29.2 5 13.5 17 11.6 Injuries & Suicide 10 45.5 8 33.3 1 2.7 9 6.1 Not elsewhere classifiable 4 18.2 2 8.3 4 10.8 36 24.5 68 | P a g e Table 8: Overall distribution of cause of deaths as per ICD 10 categories, Tamnar block, Raigarh, Chhattisgarh, 2019, (n=230) Percent of deaths Categories Adult (15 years & above) Neoplasm 4.7 (11) Cardiovascular diseases 34.34 (79) Chronic respiratory diseases 0.86 (2) Digestive diseases including cirrhosis and other chronic 6.52 (15) liver diseases Neurological disorders 0.86 (2) Mental and substance use disorder 0.43 (1) Diabetes and endocrine diseases 2.6 (6) Kidney disorders 2.6 (6) Other noncommunicable diseases 0.86 (2) Tuberculosis & HIV/AIDS 7.82 (18) Malaria 0.86 (2) Other common Infectious diseases 4.78 (11) Maternal 0.43 (1) Transports & unintentional injuries 7.82 (18) Suicide and interpersonal violence 4.34 (10) Not elsewhere classifiable 20 (46) 69 | P a g e Table 9: Causes of death by age category as per ICD 10 categories, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Categories 15-29 years 30-44 years 45-59 60 years (n=22) (n=24) years & above (n=37) (n=147) Neoplasm 0 0 10.8 4.8 Cardiovascular diseases 4.5 16.7 45.9 38.8 Chronic respiratory diseases 0 0 0 1.4 Digestive diseases including 4.5 8.3 2.7 7.5 cirrhosis and other chronic liver diseases Neurological disorders 0 0 2.7 0.7 Mental and substance use 4.5 0 0 0 disorder Diabetes and endocrine diseases 0 0 5.4 2.7 Kidney disorders 0 4.2 5.4 2 Other noncommunicable diseases 9.1 0 0 0 Tuberculosis & HIV/AIDS 4.5 16.7 5.4 7.5 Other Infectious diseases 4.5 12.5 8.1 4.1 Maternal 4.5 0 0 0 Suicide and interpersonal 22.7 8.3 2.7 1.4 violence Transports & unintentional 22.7 25 0 4.8 injuries Not elsewhere classifiable 18.2 8.3 10.8 24.5 70 | P a g e Table 10: Overall and gender-wise distribution of causes of death in the ICD 10 categories, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Diseases categories Male Female Total (n=124) (n=96) (n=230) 95% CI n % n % n % Circulatory system (I00- 51 38.1 28 29.2 79 34.3 28.23-40.87 I99) Ischemic Heart Disease 12 9 5 5.2 17 7.4 Cerebrovascular 34 25.4 16 16.7 50 21.7 disease/Stroke, Brain hemorrhage) Other (Heart failure, 5 3.7 7 7.3 12 5.2 Hypertensive chronic kidney disease, Congestive heart failure, Hypertensive heart disease with congestive heart failure) Infectious & parasitic 17 12.7 13 13.5 30 13 8.98-18.09 diseases (A00-B99) Tuberculosis 11 8.2 6 6.2 17 7.4 Malaria 1 0.7 1 1 2 0.9 HIV 1 0.7 0 0 1 0.4 Other (Leprosy, unspecified, 4 3 6 6.2 10 4.3 Sepsis, unspecified organism, Typhoid fever, unspecified, Unspecified viral encephalitis) Neoplasm (C00-D48) 7 5.2 4 4.2 11 4.8 2.41-8.40 Digestive organs (stomach, 3 2.2 2 2.1 5 2.2 liver, pancreas) Lip, oral cavity & pharynx 2 1.5 0 0 2 0.9 Female genital organs 0 0 1 1 1 0.4 Others (neck, long bones, ill- 2 1.5 1 1 3 1.3 defined site) Respiratory system (J00- 1 0.7 2 2.1 3 1.3 0.27-3.76 J99) Chronic respiratory disease 1 0.7 1 1 2 0.9 (COPD, Asthma) Lower respiratory tract 0 0 1 1 1 0.4 infection (Plural effusion) Digestive system (K00-K93) 11 8.2 4 4.2 15 6.5 3.70-10.53 Alcoholic liver disease 11 8.2 4 4.2 15 6.5 71 | P a g e (Liver disease, unspecified, chronic hepatitis, Kidney disease (N00-N99) 4 3 2 2.1 6 2.6 0.96-5.59 Chronic kidney disease 4 3 2 2.1 6 2.6 (Hypertensive CKD) - Male Female Total (n=124) (n=96) (n=230) 95% CI Disease categories n % n % n % Maternal death (O00-O99) 0 0 1 1 1 0.4 0.01-2.40 Maternal death (Gestational 0 0 1 1 1 0.4 [pregnancy-induced] hypertension without significant proteinuria, complicating childbirth) Type 1/ Type 2 diabetes 5 3.7 1 1 6 2.6 0.96-5.59 mellitus (E00-E90) (Malnutrition/ Unspecified protein calorie malnutrition) Type 2 DM (Diabetes 5 3.7 1 1 6 2.6 peripheral circulatory complication ulcer, Unspecified type 2 Diabetes with peripheral circulatory complications, Diabetes mellitus due to underlying condition with foot ulcer) External causes (Injuries & 16 11.9 12 12.5 28 12.2 8.24-17.11 suicide) (S00-Y98) Intentional self-harm 7 5.2 3 3.1 10 4.3 (Hanging, toxication) Other (Effects of lightning/ 9 6.7 9 9.4 18 7.8 thunderbolt, Unspecified cause of accidental drowning and submersion, Unspecified injury of head initial encounter, Toxic effect of unspecified snake venom, accidental (unintentional), Burn of unspecified degree of trunk, unspecified site, Motorcycle rider (driver) (passenger) injured in unspecified traffic accident) Mental & behavioral 1 0.7 0 0 1 0.4 0.01-2.40 disorder (F00-F99) 72 | P a g e Cannabis, dependence 1 0.7 0 0 1 0.4 syndrome Nervous system disorder 2 1.5 0 0 2 0.9 0.11-3.11 (G00-G99) Degenerative disease of 2 1.5 0 0 2 0.9 nervous system due to alcohol, unspecified, Motor Neuron Disease, unspecified - Male Female Total (n=124) (n=96) (n=230) 95% CI Disease categories n % n % n % Other NCD 2 1.5 0 0 2 0.9 0.11-3.11 Sickle cell anaemia, with 2 1.5 0 0 2 0.9 crisis, (D57.419) Congenital malformation of heart, unspecified (Q24.9) 17 12.7 29 30.2 46 20 15.03- Not elsewhere classifiable 25.76 Ill-defined and unknown 6 6 7 7.3 13 5.7 cause of mortality Age related physical debility 8 6 8 8.3 16 7 Unspecified abdominal pain 0 0 2 2.1 2 0.9 Diarrhea, unspecified 1 0.7 4 4.2 5 2.2 Fever, unspecified 1 0.7 8 8.3 9 3.9 other (Hemorrhage from 1 0.7 0 0 1 0.4 respiratory passage, unspecified) Table 11: Proportion of deaths in four major categories according to smoking status, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Smokers Non-smokers Overall (n=62) (n=168) (n=230) Disease category n % n % n % Noncommunicable diseases 45 72.6 79 47 124 53.9 Infectious and parasitic diseases 5 8.1 27 16.1 32 13.9 Injuries & Suicide 6 9.7 22 13.1 28 12.2 Not elsewhere classifiable 6 9.7 40 23.8 46 20 73 | P a g e Table 12: Proportion of deaths in four major categories according to alcohol use, Tamnar block, Raigarh, Chhattisgarh, 2019 (n=230) Alcohol Overall users Non-alcohol (n=230) (n=78) users (n=152) Disease category n % n % n % Non-communicable diseases 49 62.8 75 49.3 124 53.9 Infectious and parasitic diseases 11 14.1 21 13.8 32 13.9 Injuries & Suicide 6 7.7 22 14.5 28 12.2 Not elsewhere classifiable 12 15.4 34 22.4 46 20 Table 13: Proportion of deaths among neonates as per ICD 10 category, Tamnar block, Raigarh, Chattisgarh, 2019 (n=13) Disease category ICD 10 n % Birth asphyxia and respiratory distress of P22, P22.9 6 46.15 newborn Still birth P95 3 23.07 Congenital malformation of heart, unspecified Q24.9 1 7.69 Extreme immaturity of newborn, gestational age P07.23 1 7.69 24 completed weeks Newborn small for gestational P05.16 1 7.69 Unknown cause of mortality R99 1 7.69 Table 14: Place of deaths among neonates, Tamnar block, Raigarh, Chattisgarh, 2019 (n=13) Place of deaths n % Home 2 15.5 PHC/CHC/Rural Hospital 5 38.5 District Hospital 4 30.8 Private Hospital 2 15.4 74 | P a g e Table 15: Proportion of deaths among child as per ICD 10 category, Tamnar block, Raigarh, Chattisgarh, 2019 (n=10) Disease category ICD 10 n % Sickle cell anaemia, Acquired hemolytic D57.0, D59.9, D56.9 3 30 anaemia, unspecified, Thalassemia, unspecified Diarrhea, unspecified R19.7 2 20 Cerebral palsy, Epilepsy, unspecified, G80.9, G40.9 2 20 Pneumonitis due to inhalation of food and J69.0 1 10 vomit Toxic effect of venom of other arthropods T63.4 1 10 Ill-defined and unknown cause etiology R99 1 10 Table 16: Place of deaths among children, Tamnar block, Raigarh, Chattisgarh, 2019 (n=10) Place of deaths n % Home 4 40 PHC/CHC/Rural Hospital 2 20 District Hospital 3 30 Private Hospital 1 10 75 | P a g e