Evaluation of physical and mental health status of orphan children living in orphanages in Sonitpur district of Assam: a cross-sectional study

doi:10.21203/rs.3.rs-1636349/v1

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Evaluation of physical and mental health status of orphan children living in orphanages in Sonitpur district of Assam: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-1636349/v1

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Background

Orphan children living in orphanages are often neglected. These children's physical and mental health status are essential concerns as they are highly prone to malnourishment and psychosocial distress. We aim to evaluate the orphan children's physical and psychosocial status living in orphanages.

Methods

This study adopted a cross-sectional research design conducted with the children living in the orphanages using a pretested, predesigned schedule. Body Mass Index (BMI) for age and height were then determined using WHO standards. Thinness was defined as BMI for age below − 2 SD (Standard Deviation) and thinness as height for age below − 2 SD. The behavioural and mental status of the children of age 10–19 years were evaluated using the Strengths and Difficulties Questionnaire (SDQ-21) with a cut off value of SDQ score > 15 as the presence of emotional and behavioural distress.

Results

Almost 50% of orphans were in the age group of 10–14 years, 62.7% were females, and 42.2% had a primary level of education. 52.5% of orphans exhibited severe thinness for <-3SD. Observed severe thinness more among the 5–9 years and 10–14 years (p-value < 0.05) group and among the male orphans (p-value < 0.05). Out of 65 children aged 10–19 years, 18.5% had behavioural and mental distress. Emotional (32.3%) and poor conduct problems (23%) were observed significantly among male adolescents.

Conclusions

Orphaned children, particularly those living in orphanages, are at risk of malnutrition and experience various behavioural and psychosocial problems. Frequent assessments of their physical and mental health are advocated for early detection, prevention, and timely intervention.

Balanced diet

BMI

thinness

homeless children

mental health

An orphanage is a residential institution for taking care of and educating orphans. Children living in orphanages are a socially vulnerable group often neglected by mainstream society and are more prone to malnutrition [1].

About 24 million children worldwide live without their parents [2], out of which about 8 to 10 million are infants, and children live in orphanages around the globe [3]. In socioeconomically poor Asian countries, placing deprived children in orphanages has long been practised with few or no emotional and financial resources [4, 5].

Children in institutionalised care are continually in danger of malnutrition, undernutrition, overweight and micronutrient deficiencies [6], and they tend to be neglected [7]. Urban malnutrition is an increasing problem globally [8] and is more severe among children living in orphanages. Apart from malnutrition, children in orphanages also suffer from infectious diseases [9].

With its continuing concern for the health and well-being of children, particularly those existing in underprivileged living conditions, the United Nations Emergency Fund proposed a series of systematic studies under the auspices of different research agencies, including the social welfare ministry and the Government of India [4].

The most vulnerable children are those who have lost both parents as they lack the emotional and physical maturity to address their psychological trauma due to parental loss [5] and are at greater risk of developing depression and anxiety disorders [10]. Children living under institutional care often suffer from developmental and behavioural problems due to the lack of family care and support [11]. Various works of the literature suggest that the prevalence of mental and behavioural issues among those underprivileged children ranges from 18–60% [12–15]. The child's overall development is influenced by behavioural and mental problems, which may negatively impact their academic and social outcomes as adults [16].

Though limited in number, most of the orphanages in the Sonitpur district of Assam are in urban areas. Many of these orphans report various illnesses related to nutritional deficiency and are brought to the only tertiary care hospital in the region in the Sonitpur district of Assam for different diseases. Also, research about those underprivileged children's behavioural and mental status is scarce in this region. Therefore, the present study evaluates the orphan children's physical and psychosocial status living in orphanages.

A cross-sectional study was carried out at Tezpur Medical College and Hospital, Tezpur, Assam, among children aged 5 to 19 years living in orphanages in the Sonitpur district from October 2017 to October 2019. For data collection, a pretested, predesigned schedule has been used.

Anthropometric measurements were used to estimate the nutritional condition of teenagers. Height was recorded using a Stadiometer (Raja Industries, Agra, India) and weight by an electronic weight scale (Industrial weighing Machine (Activa Corporation, Tamil Nadu) wearing no shoes with light clothing. WHO guidelines were used to calculate BMI and height for age. Thinness was defined as BMI for age below − 2 SD and stunting as height for age below − 2 SD. To assess the behavioural and mental position of the orphans of age ten years and above, the Strengths and Difficulties Questionnaire (SDQ self-report version) was used [17]. An SDQ score of > 15 was considered as the existence of emotional and behavioural problems.

The SDQ is a brief mental and behavioural problem screening questionnaire for children and adolescents. It comprises 25 attributes divided into five scales, i.e., emotional, conduct, hyperactivity/inattention, peer relationship, and pro-social behaviour, consisting of five items each. There are several versions of the questionnaire available to fulfil the needs of various groups of users. There are SDQ versions for parents or educators of children aged 2–17 years and self-rated SDQ versions for 11-17-year-olds with or without impact supplements [18]. The impact supplements questions include chronicity, distress, social impairment, and burden to others, thus offering useful additional information for the observers. It has the advantage of the short format and is effective in identifying hyperactivity and inattention compared to other similar tools [17, 19] and hence widely been used across the globe [11, 20, 21]. Goodman et al. reported sensitivity of SDQ ranging from 81%-90% and specificity of 47–84% [22].

Statistical analysis

The study findings were described through counts and percentages. The Chi-square test and Fisher exact test were performed for statistical testing significance, considering a p-value of less than 0.05 as significant.

Ethics approval

Ethical clearance was obtained from the Institutional Human Ethical Committee of Tezpur Medical College and Hospital, Tezpur, Assam, India, with Ref: 20/17 dated 08/08/2017. Before collecting the data, informed consent was taken from the participant and the legal guardian in the case of a minor.

A higher number of orphans (49.4%) were between the ages of 10–14, and 62.7% were represented by females with a primary level of education for 42.2% of participants, as shown in Table 1.

Table 1

Distribution of the orphans according to socio-demographic characteristics
Socio-demographic characteristics		No. of orphans (n = 83)	Percentage
Age (in years)	5–9	18	21.7
	10–14	41	49.4
	15–19	24	28.9
Gender	Male	31	37.3
Gender	Female	52	62.7
Educational Level	Illiterate	11	13.2
	Primary School	35	42.2
	Middle School	13	15.7
	Drop-out	24	28.9

Relatively more number, 32(38.6%) orphans, exhibited severe thinness (< -3SD). The height-for-age was normal (> -2SD) for all 83(100%) orphans, as shown in Table 2.

Table 2

Nutritional status of the orphans
Nutritional status of the orphans			No. of orphans (n = 83)	Percentage
BMI for Age	Severe thinness	<-3 SD	32	38.6
	Thinness	<-2 SD to -3 SD	24	28.9
	Normal	-2 SD to + 1 SD	27	32.5
	Overweight	>+1 SD to + 2 SD	0	0
	Obesity	>+2 SD	0	0
Height for age	Severely stunted	<-3 SD	0	0
	Stunted	<-2 SD to -3 SD	0	0
	Normal	>-2 SD	83	100
(BMI- Body Mass Index; SD- Standard Deviation)

Severe thinness was more among the orphans aged 5–9 years and 10–14 years than those in the 15–19 age group, which was found significant (p-value < 0.05). Severe thinness was also more among the male orphans than the females (p-value < 0.05), as shown in Table 3.

Table 3

Age and gender-wise distribution of thinness in orphans
Demographic Characteristics		Severe thinness (32)	Thinness (24)	Normal (27)	p-value
Age (In years)	5–9 (n = 18)	11(61.1)	5(27.8)	2(11.1)	0.01
	10–14 (n = 41)	18(43.9)	11(26.8)	12(29.3)
	15–19 (n = 24)	3(12.5)	8(33.3)	13(54.2)
Gender	Male (n = 31)	21(80.0)	3(6.7)	7(13.3)	< 0.001
Gender	Female (n = 52)	11(36.0)	21(20.0)	20(44.0)	< 0.001
Figures in the brackets are the percentages

On physical examination, pallor was detected in 4(5%) cases. During a clinical dental examination, 33(40%) orphans showed unhygienic dental habits like dental staining and dental caries in 4% of cases, besides other findings like calculus and decay, as shown in Table 4.

Table 4

Distribution of orphans as per the dental examination
Signs/Symptoms	No. of orphans (n = 83)	Percentage
Normal	8	9.6
Enamel Stain	33	39.7
Malocclusion	27	32.5
Calculus	31	37.3
Gingival recession	11	13.2
Decay	16	19.3
Missing teeth	11	13.2
Irregular spacing	6	7.2
Dental caries	4	5.0
Upper anterior spacing	4	5.0

The behavioural and psychological changes of the study children were found, which were assessed with SDQ. Out of 65 children of age ten years and above, 12(18.5%) had an SDQ score > 15, among whom the majority of 8(66.7%) children belonged to the 15–19 years age group (p-value = 0.018). Out of the 12 children having an SDQ score for positive psychosocial distress, 7(58.3%) were males. However, no statistically significant association was observed between the psychological condition of the children with gender, as shown in Table 5.

Table 5

Age and gender-wise distribution of SDQ score in orphans
Demographic Characteristics		SDQ Score > 15	SDQ Score ≤ 15	p-value
Age	10–14 (n = 41)	4	37	0.018
Age	15–19 (n = 24)	8	16	0.018
Gender	Male (n = 24)	7	17	0.08
Gender	Female (n = 41)	5	36	0.08

Emotional problems were observed among 21(32.3%) children. Almost 26% of the children had poor pro-social behaviour, and 23% had conduct problems. Emotional (p-value = 0.019) and conduct problems (p-value = 0.03) were observed significantly more among the 15–19 years age group while hyperactivity (p-value 0.8), poor pro-social behaviour (p-value = 0.18) and peer problems (p-value = 0.70) were mostly experienced among 10–14 years age group, as shown in Fig. 1.

Fig: 1 Distribution of orphans as per the SDQ subscales and age

Similarly, genderwise analysis showed that emotional problems (p-value = 0.004), conduct problems (p-value = 0.006) and hyperactivity or inattention (0.046) were significantly more among males, as shown in Fig. 2.

Fig: 2 Distribution of orphans as per the SDQ subscales and age

The result reports a majority (49.4%) of orphans are in the 10–14 years age group. Vaida N [4] also reported similar findings in his study.

The majority (38.6%) of the orphans were malnourished, reflected by severe thinness of < -3SD. Reddy SB et al. [1] also reported similar findings in their study on orphans. The same research has postulated that malnourishment is 57.7%, and stunting is 53.3% among orphan children. In their research, Chowdhury, ABMA et al. [7] mentioned about 60.03% of malnourished children agree with the current findings.

Our study revealed a substantial association of thinness among orphans in different age groups (p-value < 0.05). Malnourishment was observed more among younger children than older children, supported a study [6]. The thinness in orphans was more in males for 80% than the female is well tallied with the investigations of some research [1, 7], which was significant (p-value < 0.05).

The condition was normal concerning the height for age, as 100% of children were healthy in the current study. Similarly, as per Waterloo’s Classification in a survey of Vaida N [4], height for age was found normal for more than half of the children studied.

On general physical examination, 79(95%) orphans were normal without any signs of pallor, which was found only in 4(5%) cases. The findings were similar to those reported in research [4]. The same research also supports the stained dental enamel observed in 40% of patients in the present study.

Dental caries in 5% of children in the present study were observed. It may be caused by the demineralisation of the enamel and the dentine by organic acids released from the sugars in the diet, supporting a study [23]. The organic acids increase the solubility of the calcium hydroxyapatite present in the teeth' hard tissue, resulting in demineralisation, as described in research [24].

Further, the results in the present study also revealed malocclusion in 32.5%, calculus in 37.3%, and gingival recession in 13.2%, besides decay in 19.3% of orphans, which were the signs of bad oral hygiene. The findings demonstrate a connection between diet and oral health, and the excellent state of oral health is correlated with a balanced diet. At the same time, incorrect nutritional intake relates to a form of oral disease. Some studies support these present findings [25–27].

In the present study, 18.5% of the 10–19 years old orphan children were contained with behavioural or mental distress. Those children were of different backgrounds, of other religions and diverse cultures. A study [11] reported similar findings in their research outcome.

In the current study, the orphan children primarily encountered conduct and emotional issues, particularly adolescent age and males (p-value < 0.05). A recent review [28] supports this result that orphan children are more prone to develop various behavioural and mental illnesses like depression, anxiety, and post-traumatic stress disorder. Multiple studies have cited age and gender as significant factors affecting the psychosocial status of orphan children [11, 28, 29], like our research. Children growing up and living in orphanages have low social connections and risk a lack of education, and job opportunities are the reason for their various behavioural and mental illnesses. They are more prone to develop symptoms requiring psychopathological evaluations [30] to support the needs of this kind of research.

Limitation

Average dietary recall of 24 hours could have been considered though the shelter home did not permit it. It is a single centre study. For better evaluation of different variables, a multicentre study comprising a large number of samples could have been initiated, which was not done in this study.

Malnutrition is predominantly found in orphans living in orphanages, and this aspect of malnourishment needs to be analysed systematically and addressed scientifically. The children living in orphanages need to be checked frequently so that early detection, prevention, and timely intervention may improve their nutritional status.

A poor diet is significantly associated with increased oral diseases. Dietary advice for preventing oral diseases must be a part of routine patient education practices, mainly in shelter homes. Screening of these underprivileged children's mental and psychological status should be integrated with primary health care. Specifically, counselling, and mental support should be advocated for healthy well-being among adolescents.

Body Mass Index-BMI

Standard Deviation-SD

Strengths and Difficulties Questionnaire-SDQ

Recommendation

A large sample may reflect the severity of the problem in the national context. However, the desired number of orphans was not found in the age group studied in the current study.

Ethics approval and consent to participate: Ethical clearance was obtained from the Institutional Human Ethical Committee of Tezpur Medical College and Hospital, Tezpur, Assam, India, with Ref: 20/17 dated 08/08/2017. Written informed consent was taken from the participant and the parent or legal guardian of participants below 16 years before the data collection.

Consent for publication: Taken.

Availability of data and materials: The data used to support the findings of this study are included in the article.

Competing interests: None declared.

Funding: The North-eastern centre for human and urban development (NECHURD), an academic organization, provided financial support for the study, a charitable organization at Wireless, Dispur-781006, Guwahati, Assam, India. The funding was basically to provide logistical and data collection support.

Author’ contribution: All authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation. PM, KDT and MCR mainly took part in data collection and drafting. BB, MD, SGS and RK were involved primarily in revising or critically reviewing the article. All the authors gave final approval of the version to be published, have agreed on the journal to which the article has been submitted, and agreed to be accountable for all aspects of the work.

Acknowledgements: We acknowledge the department's staff members who have helped us complete this project by providing the department's necessary infra-structures.

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You are reading this latest preprint version

Evaluation of physical and mental health status of orphan children living in orphanages in Sonitpur district of Assam: a cross-sectional study

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Background

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Results

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