Acta Universitatis Tamperensis 2331 SUSHAMA AVINASH KHOPKAR Health Profle of Adolescents Living in Slums in Nashik City, India A cross-sectional study SUSHAMA AVINASH KHOPKAR Health Profle of Adolescents Living in Slums in Nashik City, India AUT 2331 SUSHAMA AVINASH KHOPKAR Health Profile of Adolescents Living in Slums in Nashik City, India A cross-sectional study ACADEMIC DISSERTATION To be presented, with the permission of the Faculty Council of Social Sciences of the University of Tampere, for public discussion in the Lecture room F211AB of the Arvo building, Arvo Ylpön katu 34, Tampere, on 24 November 2017, at 12 o’clock. UNIVERSITY OF TAMPERE SUSHAMA AVINASH KHOPKAR Health Profile of Adolescents Living in Slums in Nashik City, India A cross-sectional study Acta Universi tati s Tamperensi s 2331 Tampere Universi ty Pres s Tampere 2017 ACADEMIC DISSERTATION University of Tampere, Faculty of Social Sciences Finland Supervised by Reviewed by Professor Suvi M. Virtanen Docent Anna Rotkirch University of Tampere University of Helsinki Finland Finland Docent Sangita Kulathinal Professor Shifalika Goenka University of Tampere Public Health Foundation of India Finland India The originality of this thesis has been checked using the Turnitin OriginalityCheck service in accordance with the quality management system of the University of Tampere. Copyright ©2017 Tampere University Press and the author Cover design by Mikko Reinikka Acta Universitatis Tamperensis 2331 Acta Electronica Universitatis Tamperensis 1835 ISBN 978-952-03-0587-1 (print) ISBN 978-952-03-0588-8 (pdf ) ISSN-L 1455-1616 ISSN 1456-954X ISSN 1455-1616 http://tampub.uta.fi Suomen Yliopistopaino Oy – Juvenes Print Tampere 2017 441 729 Painotuote Contents Title Page No. Summary 6 Tiivistelmä 9 List of original publications 12 Abbreviations 13 1. Introduction 14 2. Literature review 16 2.1 General health of adolescents in low-income countries 16 2.2 Nutrition and growth 17 2.3 Mental wellbeing 18 2.4 Blood pressure 20 2.5 Reproductive health 21 2.6 Justification of research 23 3. Aims and objectives of the study 25 4. Subjects and methods 26 4.1 Subjects and overview of the study cohorts and design 26 4.2 Ethical approval 30 4.3 Methods 30 4.3.1 Interview-administered questionnaires 32 4.3.2 Anthropometric measurements, blood pressure 33 and mental wellbeing score 4.3.3 Derived variables used in the statistical analyses 35 4.4 Statistical analyses 38 3 5. Results 41 5.1 Household characteristics 41 5.2 Characteristics of adolescents 44 5.3 Growth of adolescents (Study I) 47 5.4 Mental wellbeing and blood pressure profile (Study II) 49 5.5 Age at menarche (Study III) 52 5.6 Mental wellbeing and self-reported symptoms of reproductive 53 tract infections (Study IV) 6. Discussion 55 6.1 Summary of findings 55 6.2 Strengths and limitations of the study 57 6.3 Comparison with the results of other studies 58 7. Summary and conclusions 62 8. Implications for future research 65 Acknowledgements 67 References 70 Original publications 81 4 List of table Table No. Title Page no. ___________________________________________________________________________ 1. Aims, methods and sample size of the studies I to IV 31 2. Socio-economic characteristics of parents of adolescents 43 Under study in two slums 3. Proportion of addiction observed (%± SE) in the family members 45 and friends of the adolescents 4. Reported health status of the adolescents 46 __________________________________________________________________________________ List of figures 1. Selection of households from the two slums of Nashik city, 27 Maharashtra, India 2. Selection of adolescents from households of the two slums, Nashik city, 28 Maharashtra, India 3. Association between stunting and age in years, household size, mother's 48 education and income in INR for boys and girls, and also between thinness and these factors using mixed effects logistic regression model. Regression coefficients and 90% confidence intervals are shown 4. Association between systolic blood pressure (SBP) and mental wellbeing 51 score, thinness and parents' education, family history of hypertension, age and sex, and also between diastolic blood pressure and these factors using mixed effects linear regression model. Regression coefficients and 90% confidence intervals are shown. 5 Summary Adolescents, young people of 10-19 years of age, constitute 21% of the total population in India. Adolescents of urban slums suffer from adverse living conditions such as unsafe water, poor housing, overcrowding, and limited health facilities, especially when compared to school- going urban adolescents not living in slums. These underprivileged and often understudied young people were the focus of the research here. This was a descriptive cross-sectional study of the health and well-being of the adolescents living in two randomly selected slums of Nashik City in the state of Maharashtra in Western- central India, and was conducted during 2010-2011. The detailed data on household characteristics, parents, adolescent lifestyle and health were collected through household interviews and measurements, from 276 households and 545 adolescents. The study combined information from five topics, viz., nutrition and growth, mental well-being, blood pressure and lifestyle, reproductive health, socio-demographic variables, and attempted to achieve/answer the following main research questions and aims : 1. How is the growth, as measured by the anthropometric measurements of height and weight of the study subjects and how does it compare to the general Indian and WHO standards? How do the socio-demographic factors such as parental education, income, and diet associate with these measures? 2. What is the prevalence of hypertension in the study population and what roles do stress and mental health play on blood pressure? The secondary aim was to check the association of anthropometric measurements and lifestyle factors on mental health. 3. At what age do the girls living in slums attain menarche and is this age associated with the nutritional status and different types of oils and fat in the diet? 4. What is the prevalence of reproductive tract infections, observed using the self-reported symptoms suggestive of reproductive tract infections, and how does it associate with the mental health? The growth was assessed by stunting and nutrition status. The stunting was measured using the height-for-age score and the nutritional status using the body mass index-for-age score. The diet data considered were related to food items rich in protein, energy and fat. Mother’s education, household per capita income and the size of household were the main socioeconomic variables used in the analysis. A mental well-being score was developed and 6 used in various analyses. The different types of fat, vegetable oil, ghee (clarified butter), meat/fish/eggs and dairy products, were segregated for the analysis. The data were summarised using descriptive statistics and graphical tools, and were analysed using logistic and multivariate linear regression models, taking into account household effects. The latter was necessary because some adolescents might be from the same household. The key study findings were the following: 1. Stunting was more prevalent than thinness in the study subjects, and more common among boys (ranges of stunting 13%-41%, thinness 0%-18%, and overweight 0%-8%) than girls (ranges of stunting 4%-31%, thinness 4%-19%, and overweight 0%-10%). Mother’s higher education significantly lowered the prevalence of stunting among boys and girls and thinness in girls. In addition, having more than five household members reduced stunting, and increasing household income reduced thinness among girls. However, consumption of protein- and energy-rich food did not show any significant association. 2. The overall prevalence of prehypertension among the study subjects was 20%. Both systolic and diastolic blood pressure were significantly higher among those with worse mental status. Both types of blood pressure were significantly lower among stunted and thin adolescents while higher among overweight adolescents. The diastolic blood pressure was higher among girls and it also increased with father’s education among the adolescents. It was also observed that adolescents with worse mental status were more stunted and reported having general health- related problems. 3. The average age at menarche was 13.7 years. Height was positively associated with the consumption of ghee, and the consumption of vegetable oil was negatively associated with the age at menarche. However, consumption of dairy products, meat, fish and eggs were not associated with the age at menarche. 4. The results indicated that the symptoms suggestive of reproductive tract infection were reported by almost half of the post-menarcheal girls. Having these symptoms and low height (stunted) both negatively associated with the mental well-being. T h is study has brought out the important areas of health of adolescents living in challenging slum conditions. The research also calls for larger studies focusing on the role of mental status and blood pressure, knowledge, attitude and practice of sexual and reproductive health, and dietary habits so that proper interventions can be planned to bring about behavioural changes in these vulnerable people. The girls and women of India have gathered increasing 7 attention in recent years, however boys and men may also be in a precarious position. This study has brought out that the health and well-being of both boys and girls need to be investigated. The mother’s role is crucial in children’s growth and educating mother about children’s needs might have long-term positive effect. However, the father’s role, even though not very prominent on the surface in Indian culture, in caring for children and their well-being should not be neglected. 8