C : Health Survey
National Tuberculosis Institute, Bangalore-Report on the Baseline Survey-DANIDA Health Care Project, Tamil Nadu, 1988, NTI, Bangalore, Vol. 1, 1-88.

SURVEY DESIGN : A baseline survey was carried out in Salem and South Arcot districts of Tamil Nadu which were covered under the Danish International Development Agency (DANIDA) Health Care Project. This work was entrusted to the National Tuberculosis Institute (NTI), Bangalore, which had more than twenty years experience in conducting large scale surveys in the health sector. Overall guidance was provided by a Steering Committee under the Chairmanship of Director (Evaluation), Ministry of Health and Family Welfare, Government of India. The baseline survey of the demographic-cum-socio economic features, health status and utilization of health services was considered necessary to provide bench mark data on the beneficiaries. Equally important was to have basic information on the rural health care delivery system so that the inputs could be directed towards factors that needed strengthening and the benefits accruing maximized. The rural area of Salem and South Arcot districts were bifurcated into two strata. Stratum I consisted of all villages in which a Primary Health Centre (PHC) or sub-centre was located and the remaining villages constituted Stratum II. A sample of 40 villages were selected. The equal number of villages were allocated in each stratum, proportional to its share of the total rural population of the district. The selection of villages was made with probability proportional to size (population) of the villages, after stratification by size. Every fifth household was selected on a systematic random sample basis from each village. Thus, 2,000 households were selected in each district and 4,000 in the project area. In all, eight questionnaires were prepared for the baseline survey-four for collection of information from PHCs, Medical Officers of PHCs, Field Health Workers (FHW) and Trained Birth Attendants (Dais) and the remaining four viz., Household Schedule, Morbidity Schedule, Eligible Women Schedule and Children Schedule from the selected households. The field work was carried out during July to November 1983 by twenty investigators specially recruited and trained by NTI under the close supervision of five experienced Social Investigators of the Institute. Keeping in mind the importance of high coverage, the field teams put in lot of efforts and thereby succeeded in collecting information from 99.7% of the 4,000 households selected for the survey. Method of data collection for MOs was through a pretest questionnaire, for PHC through a questionnaire-cum-interview schedule, for FHW and Dai through interview schedule and village appraisal was done through group discussion (group consisted of village officials, informal leaders, members representing different castes, classes and women). The collected data after careful scrutiny by the statistical staff of the Institute was analysed, tabulated and reported.

FINDINGS: I. Socio-economic features: a) Literacy : Nearly half of the population of age five or more were illiterate. SC/ST population had more illiterates (58.9%) than "others" (45.8%) and had less who had school education of any level. Percentage of literates without schooling was negligible. There were no literate females in 53.8% of households (60.5% among SC/ST). In 24.9% of the households the highest level of female education was I to V standard and 17.7% VI to X standard. b) Employment: In the labour force of age group of 15-49 years, about 60% were employed. Employment among older persons was 53.5%. Children of 10-14 years of age, 6.3% were employed. This was about five times higher in Salem compared to South Arcot. Out of these employed, 45.2% were general labourers, 23% agricultural labourers and 20.6% artisans. Child agricultural labourers were more among females. The large percentage of persons who are not fully occupied for the whole year (about three-fourths of those aged 15-49 years and a substantial proportion of the elderly persons and grown up children) could be mobilised during their slack periods to carry the message of better health and hygiene as well as of the small family norm and thereby improving their financial condition also to some extent. c) Assets: About half of households did not possess any land and about 30% had less than two acres. Those not possessing any land were more among SC/ST (67.6%). Productive assets were not possessed by 65% of the households. d) Living conditions: Cowdung smeared floors were most common (65%) followed by cement floor (25%). This was more common in South Arcot (76%) compared to Salem (51%). Kerosene was used for lighting by 69% and electricity by 29%. Most of the households used foraged firewood (68%) for cooking. Almost all households (96.0%) let out used water into open place. Household waste was thrown into open yard by 65.0% and 34.6% used manure pit. Open field was used for human waste disposal by 98.4%. Provision of better sanitation arrangements and education for their utilisation needs to be taken up on large scale. The most common pests were mosquitoes (88%), flies and ants (76%), rats (40%) and cockroaches (27%). Nearly all (89%) did nothing to control these pests. The reason for this have to be investigated and suitable steps taken to remedy the situation. e) Staple diet: Main type of food was rice (50%), ragi (30%) and millets (20%). f) Major problems: The major common problems were non- availability of water (54%), health facility (49%) and transport (26%). All the three were mentioned by more households in Salem. More SC/ST households mentioned non- availability of "water" and "transport".

II. Demographic profile: The estimated rural population of 64 lakhs in the project area at the time of the survey (second half of 1983) compared favourably with that of 60 lakhs from the 1981 census. Of the population of age 15 years or more, 67.9% were currently married and 21.5% never married. The birth rate for 1982 is estimated to be 30.0 per thousand population as compared to SRS estimate of 27.7 for Tamil Nadu. The birth rate was higher in South Arcot and in Stratum II. The birth rate among SC/ST was higher in both strata of both the districts. About 98% of total births were live births. Fertility was highest in the age group 20-24 years (254) followed by 25-29 years (206) and 30-34 years (143). It was higher in South Arcot for 25-29 years, 30-34 years and 40-44 years as compared to Salem. The death rate for 1982 is estimated to be 11.0 per 1000 population. The infant mortality rate for 1982 is estimated to be 34 per 1000 live births compared with census. This gross under estimate may probably be due to some reservation or reluctance to report infant deaths possibly due to practice of infanticide by some sections of the population. As stated earlier, the proportion of child deaths out of total deaths was nearly double among females as compared to males. Of the eligible women (currently married and of age 15-49 years), 22.1% were in age group 25-29 years, 20.6% in 20-24 years, 18.0% in 30-34 years and 16.3% in 35-39 years. Thus, 42.7% were in the age group of 20-29 years with the highest fertility. Almost all eligible women had only one marriage. They had married more frequently at the age of 15-17 years (46.0%) followed by 18-20 years (32.7%). While 11.7% of the eligible women had no child. 38.8% had the first child at 18-20 years and 28.0% at 15-17 years. At the time of the survey about one tenth of the eligible women were pregnant.

III. Morbidity: During the month prior to the survey 15.4% were sick (22.2% in South Arcot and 10.6% in Salem). Among the common diseases during the three months prior to the survey, fever/flu was mentioned by 27.9%. Common cold/cough together with conditions affecting the respiratory system were reported by 22.6% and occupied second position. Conditions affecting the digestive and excretory systems (including stomach ache) were mentioned by only 13.4%. This is quite surprising since only 23.3% of the households used tap water for drinking. The 70% of households who used ground water for drinking were apparently getting water without contamination. About 42% of the sick persons did not seek treatment. This proportion was more in South Arcot (47%) compared to Salem (33%). The reasons for such a large proportion of the sick persons not seeking treatment needs to be investigated. While 39% of those who sought treatment did so from Government Health Institutions, 34% went to private doctors/institutions. More than half did not spend any money on treatment. About one fifth spent less than Rs.50/ and 7.3% between Rs.50/ and Rs.100/ . Tuberculosis prevalence rate was 5.3 per 1000 population and is well within the expected range obtained from sophisticated and costly prevalence surveys. Among the tuberculosis cases, nearly 90% had cough for 15 days or more. More than 95% of the cases had taken action to relieve their symptoms and the vast majority had gone to Government Health Institutions. Some tuberculosis cases had visited more than one type of health institutions in search of treatment. These findings are also quite similar to those obtained from sociological investigations in the field of tuberculosis. Prevalence rate of leprosy was 1.8 per 1000. The disease was more common in South Arcot (2.7) compared to Salem. When anyone is sick, 61.5% of the households go to Government doctor, 81.3% among SC/ST against 55.0% among "others". Services of private doctors were availed by 35.7% (16.9% among SC/ST compared to 41.9% among "others"). About 60% travel 5 kms or more to get treatment from Government or private doctor. The main reason for going to Government doctor was free treatment (75.4%). Only 15.0% felt that the treatment by Government doctor was good compared to 81.2% who considered that treatment by private doctor was good. Among various facilities available within 3 kms, 29.7% of households utilised the services of doctor of modern medicine, 26.1% of homeopath and 13.2% vaidya. Among those who had availed services at Government hospitals or PHC, 63.0% and 68.7% respectively had no difficulty. The more frequent difficulty mentioned was "long waiting time". During the two months prior to the survey, 53.5% of the households were visited by female health workers. More households were visited in South Arcot and among SC/ST. Family Planning: About one third of the births were attended by relative or friend, 19.4% by untrained Dai, 17.4% by doctor. Among currently pregnant women, only 32.2% had registered for ante natal care. About 60% were not given any dose of tetanus toxoid, while 15.4% got one dose and 10.7% two doses. Less than half of currently pregnant women had received iron and folic acid. About two thirds of the deliveries were conducted at home (73.9% in South Arcot compared to 56.5% in Salem and 77.3% among SC/ST against 62.2% among "others"). About one fourth of the mothers were assisted by doctors at the time of delivery, 27.0% by Dais, 9% by Female Health Workers and 35.7% by others. Help by Dais was more common in South Arcot. Currently married women of age 15-49 years (eligible women) were 161 per 1000 population. Nearly three fourths of them were illiterate (82.4% among SC/ST compared to 69.3% among "others"). About one fifth of the eligible women had tried to prevent pregnancy, the vast majority by using family planning methods. Though efforts to prevent pregnancy were comparatively more among literates, the difference was quite small. Those with 3 or 4 children more often tried to prevent pregnancy. This is not likely to have much impact on curbing of population growth. About 65% of those sterilised were below 30 years of age and the mean age of sterilisation was 27.9 years (27.3 years in Salem compared to 28.7 years in South Arcot). About half of the sterilisations were done soon after delivery, percentage of sterilised steadily decreased with increasing age of youngest child. More than three fourths felt that there was no advantage or disadvantage in having a large family. While 10.5% felt that large family led to more income, 8.5% felt that it was a burden. Among the family planning methods, male and female sterilisation were known to 94.0% and 95.8% respectively. Nearly half of the eligible women stated that they have not seen the red triangle in PHC/SHC. Those who have seen and understood the message formed only a small proportion. About two thirds of the eligible women did not know that abortion can be done at Government hospitals and 71% did not know that it can be had free of cost.