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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 1  |  Page : 57-62

Major neurological disorders in tribal areas of Himachal Pradesh: A community-based survey


1 Department of Community Medicine, Dr. S Radhakrishnan Government Medical College, Hamirpur, Himachal Pradesh, India
2 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
3 Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana, India
4 Department of Multi- Disciplinary Research Unit, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India

Date of Submission25-Jul-2021
Date of Decision12-Oct-2021
Date of Acceptance01-Dec-2021
Date of Web Publication24-Jan-2022

Correspondence Address:
Dr. Mitasha Singh
Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_195_21

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  Abstract 

BACKGROUND: Neurological disorders are being recognized as a part of epidemiological transition worldwide. The much-needed database on neurological diseases in India is lacking.
OBJECTIVE: The objective of this study was to estimate the prevalence of major neurological disorders in tribal population of Himachal Pradesh.
METHODOLOGY: A community-based survey was conducted in two tribal districts and two tribal blocks of one district of Himachal Pradesh, India. A cluster-randomized sampling technique was used to study a population of 10,000 between 2017 and 2018. Forty clusters were identified in three districts. The study was conducted in two phases in individuals above 7 years of age. The individuals screened positive in stage 1 (using the National Institute of Mental Health and Neurosciences protocol for assessing neurological disorders) were examined by clinical team in stage 2 and classified.
RESULTS: A total of 8255 individuals reported for phase two of the study (response rate of 82.55%). The crude prevalence of neurological disorders in the tribal population was 3.04% after clinical assessment in stage 2. Migraine (1.9%) was the most common disorder followed by stroke (0.47%).
CONCLUSION: The prevalence of neurological disorders in tribal populations is comparable to the general population. This is an indicator of lifestyle diseases entering into the indigenous population and demands neurological health care tailored in primary health care.

Keywords: Cross-sectional survey, hilly tribes, neurology, two stage


How to cite this article:
Bhardwaj A, Raina S, Kumar S, Singh M, Kumar D, Sharma P. Major neurological disorders in tribal areas of Himachal Pradesh: A community-based survey. Indian J Health Sci Biomed Res 2022;15:57-62

How to cite this URL:
Bhardwaj A, Raina S, Kumar S, Singh M, Kumar D, Sharma P. Major neurological disorders in tribal areas of Himachal Pradesh: A community-based survey. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 May 22];15:57-62. Available from: https://www.ijournalhs.org/text.asp?2022/15/1/57/336300




  Introduction Top


The Global Burden of Disease (GBD) study in 2016 demonstrated that neurological disorders were the leading cause of disability-adjusted life years (276 million [95% UI 247–308]) and the second-leading cause of deaths (9·0 million [8·8–9·4]) worldwide.[1] Tribal population in Himachal Pradesh, India, constitute about 3.9% of the total population of the state and is mostly concentrated in two tribal districts and two tribal blocks (Chamba district) of the state.[2] The sociodemographic and epidemiological transition in this population has changed the morbidity and mortality pattern among these communities. The noncommunicable diseases are highlighted in the health-seeking pattern of these communities. The epidemiological data thus obtained will be valuable in understanding the factors leading to the development of neurological disorders.

Indigenous tribes are described as people who follow traditional nonindustrial lifestyles in areas that they have occupied for generations.[3] Their lifestyle and genetic makeup make them different from the general population. Industrialization and globalization have touched upon these tribes too. It is of interest to study the pattern of noncommunicable diseases among this population to deliver timely health services and preserve the health of these tribes. Community-based surveys using standardized methodology to screen neurological disorders are few, and only one has been conducted among tribes that too in Gujarat.[4]

The cases referred from peripheral health centers of tribal areas of four of the districts of Himachal Pradesh to the tertiary care center of district Shimla and Kangra, Himachal Pradesh, raised curiosity to quantify the burden of neurological disorders among the indigenous population. Hence, a community-based survey was planned to estimate the prevalence and pattern of major neurological disorders in the tribal population of Himachal Pradesh


  Methodology Top


Study design

A community-based cross-sectional survey was conducted.

Study area

The study was conducted in two tribal districts of Kinnaur, Lahaul and Spiti, and two tribal blocks of district Chamba (Pangi and Bharmour) of the state of Himachal Pradesh. Kinnaur is surrounded by the Tibet to the East, in the northeast corner of Himachal Pradesh. It is spread in an area of 6401 sq km, has a population of 84,121, ranging in altitude from 2320 to 6816 meters. Lahaul and Spiti is the fourth-least populous district in India. The valley of Lahaul is situated to the South of Ladakh. Its western boundaries touch Distt. Chamba. Its eastern and southeastern boundaries overlap with those of Spiti and Western Tibet across the Kunzum Pass (4500 Mtrs). Pangi is a tribal block in the Chamba district. It is inhabited at 2100 meters to 3400 meters. The Pangi tehsil covers 1601 square kilometers and has a population of 18,868 as per the 2011 census. Bharmour block is situated at an altitude of 7000 feet in the Budhil valley of district Chamba.[2],[5],[6]

Study duration

The survey was conducted between June 2017 and November 2018.

Study population

Individuals above 7 years of age and consenting to be a part of the study were included in the study.

Sample size

A sample size of 10,000 individuals spread over three districts (two tribal and one with two tribal blocks) was calculated with the assumption that this sample size will provide us with the prevalence on major neurological disorders in tribal areas of Himachal Pradesh. Importantly, the sample size was spread over socioeconomically different tribal blocks with two blocks of relatively poor socioeconomic status.

Sampling

Cluster sampling technique was used for the purpose of the study. All the revenue villages falling under the selected tribal areas were identified and labeled as the primary sampling unit for selecting the study population. Thereafter, the villages were spread into clusters, and clusters were listed. A total of forty clusters (ten each from four selected geographical locations) were identified, and sample size of 10,000 was collected from these forty clusters. Further, 250 (10,000/40 = 250) individuals of more than 7 years of age were recruited from each selected cluster. The study population (above 7 years of age) was selected by simple random technique. After starting from the bus stand area of each village, one of the lanes was selected randomly by the lottery method using a currency note. Subjects were approached in their homes starting from the one side of the lane (after the toss of a coin in choosing the sides of lane). The process was repeated in similar manner in other lanes till a desired sample size of 250 was achieved. If sample could not be achieved from a revenue village of the selected cluster, then the adjoining village was selected, and house-to-house survey was carried out accordingly to complete the desired sample.

Strategy

The study was completed in two phases.

Phase I: (Screening phase)

The screening phase was carried out by the field staff trained in the screening of neurological disorders administering the study questionnaire to the consenting individuals above 7 years of age. The study questionnaire was administered by the field workers in the household settings through a house-to-house survey. All eligible individuals, fulfilling inclusion criteria, were contacted. Individuals absent from their homes at the time of visit were requested to report at the local/nearby Anganwadi center on the subsequent day. Interviews were conducted in local languages from the head of the household or surrogate respondent, who was able to provide information for each family member of the selected household.

The screening instruments consisted of parameters for information on sociodemographic characteristics of the households and a modified version of the National Institute of Mental Health and Neurosciences protocol for assessing the presence of neurological disorders.[7]

Phase II (clinical phase)

In stage II, all individuals who responded positive to screening protocol in stage I were invited to undergo examination by a clinical team under standard conditions. To maintain the operational definitions of various neurological disorders and to have a uniform case definition and classification, a symptom-based classification was used for analysis.

Clinical team comprised neurologists, pediatricians, physicians, and public health experts at a time. Neurologists' diagnosis was considered as gold standard for defining a suspected and confirmed case.

Data and statistical analysis

The data collected were entered in Microsoft Excel software and double-checked for duplicate and missing information. Analysis was conducted using Epi Info version 7 (Centers for Disease Control and Prevention, USA). The descriptive data were presented as mean and proportions.

Ethical consideration

This analysis was a part of the Indian Council of Medical Research (ICMR) funded project which was conducted after approval from the Institutional Ethics Committee of Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh (IEC No. HFW-HP-DRPGMC/Ethics/2016/44 dated 11.10.2016).


  Results Top


Out of a total of 10,000 individuals, only 8255 individuals reported for phase two of the study yielding us response rate of 82.55% for the second phase. There was no significant difference in age distribution among different age groups and gender distribution also showed no significant difference. Mean age was 35.7 ± 17.89 [Table 1].
Table 1: Age and gender distribution of study participants

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Around 38.2% of the participants were having secondary-level education and 15.2% were illiterate. Only 2% of the participants were having the professional degree [Table 2].
Table 2: Distribution by educational status

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In 8255 participants, 1602 positive responses were recorded and more than one positive response was given by some participants in stage 1. The crude prevalence of neurological disorders was 3.04% in the study population after clinical assessment by neurologists in stage 2. It was more in males (3.8%) as compared to females (2.2%) and was statistically significant (P < 0.000). Migraine was major disorder (1.9%) [Table 3]. Migraine was diagnosed to be highest among 36–45 years age group (33.5%). Dementia was diagnosed among tribals of age above 66 years [Table 4].
Table 3: Prevalence of neurological disorders in study population (n=8255)

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Table 4: Age-wise distribution of neurological disorders in study population (n=251)

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  Discussion Top


Increased life expectancy of the population has brought with itself the noncommunicable diseases and progressive disorders like neurological diseases. The global evidence on the burden of neurological disorders is still deficient leave aside the subgroups of population. Population-based studies estimating the prevalence of neurological disorders have been initiated mostly in rural Bangalore, Bombay, Delhi, Gujarat, and Kashmir.[8] The current study revealed a crude prevalence of neurological disorders of 3.04% in the tribal population. The crude prevalence rate from six studies conducted between 1982 and 1995 varied from 0.967 to 4.070% with an average of 2.394%. The prevalence rate of neurological disorders among the tribal population of Gujarat was 2.592%.[4] Neurological disorders constitute 16.8% of the total deaths in lower-middle-income countries as per the GBD study, 2005.[1],[9] This proportion increased by 39% (number of deaths from all neurological disorders) by the 2015 GBD study.[1]

The prevalence of neurological disorders in this study was higher among males similar to the findings by Das et al., in Kolkata.[10] Our findings are contrary to those community-based surveys from Bangalore and Malda, where the prevalence was higher among females.[11],[12]

The prevalence of migraine in the present study was 1.9% and highest as compared to other disorders. This was similar to the estimates obtained by Devi et al., wherein the prevalence was 1.26% in rural areas of Bangalore.[11]

The prevalence of stroke was 0.4% in our study. Kalkonde et al., from a rural area of Gadchiroli reported somewhat similar prevalence of 0.39%.[13] Mansukhani et al., reported the prevalence of stroke from tribal population of Gujarat to be 0.11%.[4] The prevalence estimates from Bangalore for cerebrovascular disorders was 0.15%. Male preponderance was observed in our study and this was in line to other studies from Maharashtra and Kolkata.[10],[13],[14] The crude prevalence rates of strokes in the studies conducted in various regions of the country varied from 52 to 472 per 100000 persons, with the exception of a very high rate of 842 among Parsis, a distinct ethnic community.[11],[12],[15],[16],[17],[18],[19],[20],[21],[22]

The prevalence of cerebral palsy was 0.08% in the present study comparable to the study done by Raina et al. in Jammu and Kashmir.[23] The estimated prevalence of cerebral palsy around the world range from 1.5 to more than 4 per 1000 live births.[24],[25],[26],[27]

Prevalence of dementia in the present study was 0.06%. Das et al.,[10] reported the prevalence of dementia in Kolkata to be 0.139%. The 10/66 multicountry dementia study conducted in Latin America, India, and China reported crude prevalence rate ranging from 0.8% in rural India to 4.6% in urban Latin America.[28] Raina et al., in a survey in Pangi valley of Himachal Pradesh on geriatric population reported a prevalence of 1.2% using Bharmouri Mental State Examination.[29] In another study by Raina et al., the prevalence of dementia from four different regions of Himachal Pradesh showed that the prevalence was higher among urban elderly population (3.2%) as compared to rural elderly (1.4%).[30] In 2010, a study conducted among two ethnically different population groups living within the same geographical region of North India revealed a significant difference in the prevalence of dementia among individuals aged 60 years and above.[31] Hence, indigenous tribes still have a low prevalence of dementia as compared to rural, urban, and migrants.

The prevalence of epilepsy was 0.35% in the tribal population. The prevalence estimates of epilepsy in India for the general population in 2019 were higher; ranging from 3·0 to 11·9/1000 of the population.[32] However, still, lack of knowledge and poor attitude toward early treatment-seeking makes it difficult to control the complications.

Limitation

The response rate in phase two of the study was 82.55% from phase one which may have missed out on many of the cases. Reasons could be geographical barriers in the hard-to-reach areas as camp was set at health center of clusters; people tend to forget dates as they perceived it less important as compared to routine work.


  Conclusion Top


This community-based survey on tribal populations residing in geographically hard-to-reach and high-altitude areas gave a crude prevalence of neurological disorders to be 3.04%. It adds to the evidence of few community surveys on the tribal population. The burden is expected to rise in future highlighting the need of trained neurologists, integration of neurological care in general health care. Adequate neurology services have to be provided with essential workforce and infrastructure for the tribal population in remote areas of the country. Telemedicine and community health center model approach are the need of hour.

Acknowledgments

The authors would like to extend their gratitude to ICMR for funding this community-based survey. Furthermore, we would like to thank the team of neurologists and physicians who participated in the clinical assessment of the participants. The work would have been impossible without the support of Director Health Services HP and Chief Medical Officers of Kinnaur, Lahaul &Spiti, and Chamba. The local leaders of the clusters need special mention in arranging camps and motivating people.

Financial support and sponsorship

This study is a part of project funded by the Indian Council of Medical Research (ICMR) (vide no. 5/4-5/108/Neuro/2013-NCD-1). The IRIS no. is ICMR (2013-21310), dated March 9, 2011.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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