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   2012| July-December  | Volume 1 | Issue 2  
    Online since December 20, 2012

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A Public Health Perspective of Road Traffic Accidents
S Gopalakrishnan
July-December 2012, 1(2):144-150
DOI:10.4103/2249-4863.104987  PMID:24479025
Road traffic accidents (RTAs) have emerged as an important public health issue which needs to be tackled by a multi-disciplinary approach. The trend in RTA injuries and death is becoming alarming in countries like India. The number of fatal and disabling road accident happening is increasing day by day and is a real public health challenge for all the concerned agencies to prevent it. The approach to implement the rules and regulations available to prevent road accidents is often ineffective and half-hearted. Awareness creation, strict implementation of traffic rules, and scientific engineering measures are the need of the hour to prevent this public health catastrophe. This article is intended to create awareness among the health professionals about the various modalities available to prevent road accidents and also to inculcate a sense of responsibility toward spreading the message of road safety as a good citizen of our country.
  50 11,058 1,755
Morbidity Profile and Seasonal Variation of Diseases in a Primary Health Center in Kanpur District: A Tool for the Health Planners
Ranjeeta Kumari, Bhola Nath, Tanu Midha, Narain D Vaswani, Seema Lekhwani, Bhupendra Singh
July-December 2012, 1(2):86-91
DOI:10.4103/2249-4863.104943  PMID:24479013
Objective: The objective of this study was to determine the morbidity profile of patients being treated at the Primary Health Center, their distribution according to gender, and the seasonal trend of diseases. Materials and Methods: The study was done retrospectively using secondary data, over a period of 1 year from June 2007 to July 2008, at the OPD of the Primary Health Center at Patara in Kanpur District, India. The study was aimed to study the pattern of diseases according to the classification provided by the Government of India. The data were collected from the OPD registers of the consultant medical officer, and the diagnosis was classified into communicable diseases, nutritional and metabolic disorders, infectious diseases, obstetric complications, and other diseases including injuries. Results: A total of 6838 patients had been treated at the OPD, which included 2707 males and 4131 females. It was observed that, while communicable diseases constituted about half of the total burden of the diseases with skin infections being the commonest; the non-communicable diseases constituted about one-fifth of the total disease burden. Significant gender differences were evident in the prevalence of certain diseases such as worm infestation, acute respiratory tract infection, urinary tract infection, reproductive tract infection, chronic obstructive pulmonary disease, gastritis, arthritis/gout, falls/injuries/fractures, anemia, pyrexia of unknown origin, and snake bite. Most of the diseases were observed to have a seasonal variation, with the communicable and infectious diseases peaking in the monsoon months. Surprisingly, the non-communicable diseases such as gastritis and falls and injuries also showed a seasonal variation. Conclusion: Many diseases have a seasonal variation and the burden of these diseases could be reduced if we devise measures to detect the changes in their trend through the implementation of surveillance programs in this part of the world, as has been carried out in other countries. The knowledge of the burden of the diseases would also assist the health administrators in judicious allocation of the resources.
  10 4,310 1,164
Salmonella Hepatitis: An Uncommon Complication of a Common Disease
Ritu Karoli, Jalees Fatima, Ashok Chandra, Gagandeep Singh
July-December 2012, 1(2):160-162
DOI:10.4103/2249-4863.104992  PMID:24479030
Typhoid fever is a very common infectious disease of tropics, associated with high morbidity and mortality. Typhoid fever is often associated with hepatomegaly and mildly deranged liver functions; a clinical picture of acute hepatitis is a rare complication. We report a young patient who presented with fever and jaundice and was found to have acute hepatitis secondary to typhoid fever. Recognition of Salmonella hepatitis is of clinical importance as it can mimic acute viral hepatitis. Early institution of specific therapy can improve the prognosis in these patients.Typhoid fever is a very common infectious disease of tropics, associated with high morbidity and mortality. Typhoid fever is often associated with hepatomegaly and mildly deranged liver functions; a clinical picture of acute hepatitis is a rare complication. We report a young patient who presented with fever and jaundice and was found to have acute hepatitis secondary to typhoid fever. Recognition of Salmonella hepatitis is of clinical importance as it can mimic acute viral hepatitis. Early institution of specific therapy can improve the prognosis in these patients.
  7 3,150 562
Birth Order and Psychopathology
Ajay Risal, Hema Tharoor
July-December 2012, 1(2):137-140
DOI:10.4103/2249-4863.104985  PMID:24479023
Context: Ordinal position the child holds within the sibling ranking of a family is related to intellectual functioning, personality, behavior, and development of psychopathology. Aim: To study the association between birth order and development of psychopathology in patients attending psychiatry services in a teaching hospital. Settings and Design: Hospital-based cross-sectional study. Materials and Methods: Retrospective file review of three groups of patients was carried out. Patient-related variables like age of onset, birth order, family type, and family history of mental illness were compared with psychiatry diagnosis (ICD-10) generated. Statistical Analysis: SPSS 13; descriptive statistics and one-way analysis of variance (ANOVA) were used. Results: Mean age of onset of mental illness among the adult general psychiatry patients (group I, n = 527) was found to be 33.01 ± 15.073, while it was 11.68 ± 4.764 among the child cases (group II, n = 47) and 26.74 ± 7.529 among substance abuse cases (group III, n = 110). Among group I patients, commonest diagnosis was depression followed by anxiety and somatoform disorders irrespective of birth order. Dissociative disorders were most prevalent in the first born child (36.7%) among group II patients. Among group III patients, alcohol dependence was maximum diagnosis in all birth orders. Conclusions: Depression and alcohol dependence was the commonest diagnosis in adult group irrespective of birth order.
  5 3,395 556
Behavior of Personality Type Toward Stress and Job Performance: A Study of Healthcare Professionals
Yasmin Janjhua, Chandrakanta
July-December 2012, 1(2):109-113
DOI:10.4103/2249-4863.104969  PMID:24479017
Background: The present paper has examined the sources of stress among the healthcare professionals and the difference between responses of personality type A and type B healthcare professionals toward stressful situations. Further, the difference in the performance of both the personality types has been studied. The relationship between stress and performance among the healthcare professionals in general and with respect to personality type A and type B healthcare professionals in particular has also been investigated. Methods: A total of 160 healthcare professionals of Post Graduate Institute (PGI), Chandigarh, were subjects of this study. Results: Identification with patients, deterioration and complication in the patient condition, and job criticism emerged to be the sources of stress. Significant difference between personality type A and personality type B professionals' response pertaining to identification with the patients only has been reported. However, type A individuals showed slightly higher inclination as compared to type B individuals on majority of stressful situations. It was further noted that type A individuals had scored higher on almost all the performance indicators as compared to personality type B individuals. The mean difference between the personality types was found to be significant for two performance dimensions, i.e., relationship with colleagues, and teaching and training. Conclusions: The stressful situation relationship with patients was found to have significantly negative impact on the performance factors such as good clinical care and rapport with patients. Daily work was also found to be negatively related to good medical practice.
  4 5,210 700
Healthcare Technician Delivered Screening of Adults with Diabetes to Improve Primary Care Provider Recognition of Depression
Melissa Scollan-Koliopoulos, Iris Herrera, Karen Romano, Carrie Gregory, Kenneth Rapp, David Bleich
July-December 2012, 1(2):97-102
DOI:10.4103/2249-4863.104955  PMID:24479015
Purpose: The purpose of this study was to implement a continuous quality improvement project aimed at improving primary care provider recognition of depression. Materials and Methods: A randomized, blinded, pre- and post-test design was implemented with 92 adults attending an academic internal medicine clinic. Subjects were assigned to an intervention where healthcare technicians (HCT) trained in the fundamentals of diabetes education delivered brief probing questions about self-care behavior and tailored talking points to encourage patients to talk to their primary care physician about their emotional health. The control group received a sham intervention that included only information on standards of diabetes care. Measures included both a paper-and-pencil screening of depression and the Primary Healthcare Questionnaire-8 (PHQ-8). Outcomes were evaluated for antidepressant and/or counseling treatment modalities once the possibility of depression was identified. Results: Both the control and intervention groups improved from pre-test to 3-month post-test scores on the PHQ-8 in clinically significant ways, but continued to have moderate to severe depression symptoms. There was a significant likelihood of receiving antidepressant therapy and/or counseling in those who scored high on the PHQ-8. Conclusion: HCT can be trained to talk to patients about emotional health issues during routine primary care visits. Depression screening measures can be administered as part of the triage routine at the start of a primary care visit, along with tasks such as vital signs. Answering a screening measure can help create awareness of symptoms and feelings that can prompt discussion during the patient-provider encounter that can result in the diagnosis and treatment of depression.
  4 2,439 421
Polio eradication: Current status and challenges
Soumyadeep Bhaumik
July-December 2012, 1(2):84-85
DOI:10.4103/2249-4863.104936  PMID:24479012
For more than two decades mankind has been dreaming of a "polio-free world." However the dream is yet to be realized owing to various problems related to transmission of wild polio virus transmission as well as vaccine-derived polio virus. These problems are as much scientific as human. The article briefly discusses the current status of polio control across the globe, and various challenges associated with it in a nation-wise manner.
  4 4,163 2,985
Strengthening Primary Level Health Service Delivery: Lessons from a State in India
Prahlad Rai Sodani, Kalpa Sharma
July-December 2012, 1(2):127-131
DOI:10.4103/2249-4863.104983  PMID:24479021
The main aim of the study was to assess primary health centers (PHCs) in terms of availability of assured services, facility of primary management of selected cases, surgeries, maternal and newborn health care services, and child health care services with respect to Indian Public Health Standards (IPHS). Data were collected from service providers (medical officerin-charge) at PHCs through well-structured questionnaire developed by referring the IPHS for PHCs prescribed by the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. The study was conducted at five districts (i.e. Bundi, SawaiMadhopur, Kota, Tonk, and Karauli) of Rajasthan state of India. All 148 PHCs of these five districts were included in the study. Findings depict that more than 90% of the study PHCs showed availability of services such as outpatient department (OPD), antenatal check up (ANC), postnatal check up (PNC), management of reproductive tract infections/sexual transmitted infection (RTI/STI), immunization, and treatment of diarrhea. However, services such as emergency services (24 h), primary management of fractures, surgery of cataract, medical termination of pregnancy (MTP) services, management of low-birth-weight babies, facility for tubectomy and vasectomy, and facility for internal examination for gynecological conditions were poor at PHCs of the study districts, which need to be addressed for further strengthening of primary health centers.
  3 2,964 542
Age and BMI Adjusted Comparison of Reproductive Hormones in PCOS
Hana Fakhoury, Hani Tamim, Mazen Ferwana, Imran A Siddiqui, Maysoon Adham, Waleed Tamimi
July-December 2012, 1(2):132-136
DOI:10.4103/2249-4863.104984  PMID:24479022
Objective and Background: Polycystic ovary syndrome (PCOS) is a complex condition and has been described in women who have polycystic ovaries as the underlying cause of hirsutism and chronic anovulation. Studies on PCOS in the Saudi population are very few. The aim of this study was to investigate the reproductive hormones levels in patients with PCOS. Effect of age and body mass index (BMI) on the hormonal findings was eliminated through a multivariate analysis. Materials and Methods: A comparative study was conducted on Saudi subjects attending the outpatient clinic of National Guard Hospital in Riyadh. A total of 62 cases with PCOS and 40 healthy Saudi women were included in this study. Physical evaluation and laboratory investigations were carried out. Blood luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol (E2), dehydroepiandrosterone sulfate (DHEA-SO 4 ), sex hormone-binding globulin (SHBG), total testosterone, prolactin, and progesterone were determined. To adjust for the potentially confounding effect of age and BMI, we carried out multivariate linear regression analyses for the association between each of the reproductive hormones and PCOS. Results: Serum levels of FSH, SHBG, and progesterone were significantly lower in PCOS compared to controls (respective P values 0.001, 0.001, and 0.002), while LH/FSH and testosterone levels were higher in PCOS cases than in controls (P = 0.008 and 0.003, respectively). When multivariate linear regression analyses were carried out, LH/FSH and total testosterone were positively correlated with the disease [95% confidence interval (CI) = 0.02-0.35 and 0.02-0.17, respectively], whereas FSH, SHBG, and progesterone were negatively correlated with the disease (95% CI = -0.06 to 0.001, -0.01 to 0.001, and -0.17 to -0.03, respectively), independent of age and BMI. Conclusion: Our study suggests that regardless of the age and weight factors, Saudi patients with PCOS have higher levels of LH/FSH and total testosterone; but have lower levels of FSH, SHBG, and progesterone compared to controls.
  3 2,857 480
Overwork Among Residents in India: A Medical Resident's Perspective
Gulrez S Azhar, Abdullah Z Azhar, Ahmad S Azhar
July-December 2012, 1(2):141-143
DOI:10.4103/2249-4863.104986  PMID:24479024
This paper argues that medical residents who do most of the hard work in big hospitals and medical colleges are overworked. A hierarchical organizational structure, staffing patterns, and fear of failure in examinations leads to overwork among residents going unreported. This can lead to poor academic performance and research work. Gaps in communication have serious implications on patient health. Undesirable practices like LAMA (leave against medical advice) also result from overwork. Issues of pay and contracts including mandatory service need to be looked into carefully. National and international recommendations on work hours have consistently been ignored. The solutions suggested are simple and easy to implement.
  3 4,526 394
Family medicine at AIIMS (all India institute of medical sciences) like institutes
Raman Kumar
July-December 2012, 1(2):81-83
DOI:10.4103/2249-4863.104925  PMID:24479011
  2 5,864 9,883
Patients' Attitudes Towards Medical Students in a Teaching Family Practice: A Sri Lankan Experience
R.P.J.C. Ramanayake, W.L.A.H. Sumathipala, I.M.S.M. Rajakaruna, D.P.N. Ariyapala
July-December 2012, 1(2):122-126
DOI:10.4103/2249-4863.104982  PMID:24479020
Background: Faculty of Medicine, University of Kelaniya, Sri Lanka conducts a one month under graduate training programme during their fourth year at the University family practice centre. Students get training in history taking, clinical examination, patient management and practice management during this attachment. This study was conducted to look at the patients' attitude towards student participation during consultation. Materials and Methods: This was a descriptive cross sectional study. All the patients who were 16 years and above during a 2 month period were included in the study. Structured questionnaire was administered by demonstrators following a consultation where students were present. Their demographic data, number of consultations with student participation and questions related to presence of students at various stages of the consultation were asked. Results: Total of 85 patients took part in the study and 81.3% of them were females. 88.8% were of the opinion that they benefited by the interaction with medical students while 93.8% thought students understood their problems. 26.3% patients preferred a medical student of the same sex during consultation while 71.3 had not expressed any opinion in this regard. Only 3.8% and 5% wanted the doctor alone during history taking and examination respectively. Almost every patient was happy that they could help the undergraduate training. Discussion: As expected results of the study showed that patients were willing to take part in undergraduate training without any reservation. These results are compatible with the previous studies done in the western world and data is not available form either Sri Lanka or other Asian countries.
  2 2,291 368
Poly-resistant Tuberculosis in an HIV-infected Child
Ira Shah, Neha Bansal
July-December 2012, 1(2):153-154
DOI:10.4103/2249-4863.104989  PMID:24479027
Drug-resistant tuberculosis (DR-TB) has been reported in India, but has been rarely documented in children. HIV co-infection has led to resurgence of tuberculosis (TB), making treatment even more difficult due to complex drug interactions. Poly-resistant TB is rare in children, especially in HIV-infected children. We report an HIV-infected child who developed poly-resistant TB (resistance to Streptomycin and Isoniazid) after 3 years of completion of anti-tuberculosis treatment (ATT). His mother had also received ATT 3 years back. We conclude that DR-TB in HIV-infected children should be considered if the child had been treated with ATT in the past or there is contact with adults on second-line ATT therapy.
  1 2,353 300
Screening of Vision and Hearing in Primary School Children
Martin Lehmann Boesen, Kirsten Lykke
July-December 2012, 1(2):114-117
DOI:10.4103/2249-4863.104979  PMID:24479018
Background: Hearing and sight are two basic senses in terms of education and profession. The World Health Organization (WHO) estimates that 15 million children worldwide suffer from uncorrected refractive disorders and another 275 million people are handicapped due to compromised hearing. In Indonesia, screening primary school children for hearing and vision is not part of the free public health-care system. Knowledge of the status of a child's hearing and vision may help secure the child's education and future profession. Materials and Methods: In five primary schools in a poor urban neighborhood in Yogyakarta, Indonesia, we screened pupils from class 1 to 6, for vision and hearing handicaps, following the WHO's definitions of handicap. On location in the primary schools, we screened vision using a Snellen chart and hearing using distortion product otoacoustic emission (DPOAE). Those with vision below 6/18 were referred to an ophthalmologist and pupils with hearing below 30 decibels at 0.5, 1, 2, and 4 kilohertz were referred to an ear nose and throat (ENT) specialist for final testing. Results: Totally, 775 pupils were vision screened and 777 pupils were hearing screened. We found that 2% were disabled by sight and 6% by hearing. Conclusion: Lost without proper education, these pupils can, with simple recommendations, have access to education. We recommend that Indonesia start screening its primary school pupils for hearing and vision to secure the country's future productivity and socioeconomic development.
  1 2,312 417
A Case of Pulmonary Tuberculosis Presenting as Multiple Nodular Opacities on a Chest X-Ray
Apurva Pande, Dutiman Guharoy
July-December 2012, 1(2):155-156
DOI:10.4103/2249-4863.104996  PMID:24479028
Tuberculosis is widely prevalent in India. The presentation of pulmonary tuberculosis as multiple nodular opacities on a chest X-ray is very infrequent. We report such a case in a 30-year-old man, who presented with the complaints of dyspnea and responded to anti-tuberculosis treatment.
  - 4,233 386
Diabetes, Fever and Flank Pain: Is it Emphysematous Pyelonephritis?
Sujeet Raina
July-December 2012, 1(2):157-159
Fever and flank pain in a diabetic patient should raise the suspicion of emphysematous pyelonephritis (EPN). The clinical course of EPN can be severe and life threatening, if not recognized and treated promptly. Gas shadows in the renal or perirenal region on plain X-ray, ultrasound, or computed tomography (CT) scan of the abdomen are the radiological features of EPN. However, CT scan of the abdomen is sine qua non for classification, treatment options, and prognosis.
  - 2,817 353
Dopa-Responsive Dystonia in a Ten-Year-Old Girl
Venkatesh Soma, Hussain Sadiq Mohammed, Ebrahim Riyas, Karuppasamy Murugesan
July-December 2012, 1(2):151-152
DOI:10.4103/2249-4863.104988  PMID:24479026
Children with recent onset dystonia and gait abnormalities may pose a diagnostic challenge. A ten-year-old, developmentally normal girl, presented with a six-month history of gait abnormality and dystonia. Her complaint worsened as the day progressed. In view of typical diurnal variation of dystonia, a therapeutic challenge with levodopa/carbidopa was given and there was a dramatic response. Hence, a diagnosis of dopa-responsive dystonia (DRD) was made. DRD is an inherited disorder characterized by dystonia with diurnal variation and favorable response to levodopa/carbidopa. The inheritance is usually autosomal dominant, however, in some cases, autosomal-recessive inheritance is also seen.
  - 3,148 421
Prazosin, Scorpion Sting and Dr. Bawaskar
Yerramilli V. Siva Sankara Murty
July-December 2012, 1(2):163-163
DOI:10.4103/2249-4863.104993  PMID:24479031
  - 2,265 314
Common Geriatrics Cases Seen by a General Practitioner in an Urban Area of Jharkhand State, India
Keshab Mukhopadhyay, Ritesh Singh
July-December 2012, 1(2):164-165
DOI:10.4103/2249-4863.104994  PMID:24479032
  - 1,691 333
Quality of Water Distribution System in a Rural Area of Puducherry, India
S Ganesh Kumar, Gautam Roy, Sitanshu Sekhar Kar, Suman Saurabh
July-December 2012, 1(2):165-166
DOI:10.4103/2249-4863.104995  PMID:24479033
  - 2,073 294
Study of Clinical Profile and Antibiotic Sensitivity in Paratyphoid Fever Cases Admitted at Teaching Hospital in South India
Vinay Pandit, Ashwini Kumar, Muralidhar Madhav Kulkarni, Sanjay M Pattanshetty, Charmine Samarasinghe, Sneha Kamath
July-December 2012, 1(2):118-121
DOI:10.4103/2249-4863.104981  PMID:24479019
Context: Globally, there has been an increase in incidence of paratyphoid fever, including paratyphoid fever caused by antimicrobial-resistant strains. Studying the clinical profile and antimicrobial sensitivity of paratyphoid fever would help in early diagnosis, appropriate treatment, rational use of antibiotics and prevent drug resistance. Aim: The aim of the study was to evaluate the clinical profile and sensitivity patterns of antibiotics used in the treatment of paratyphoid fever. Settings and Design: A record-based study was done in tertiary care hospital, South India. Materials and Methods: A retrospective analysis of culture-proven cases of paratyphoid fever was done in a tertiary care hospital. The socio-demographic characteristics, mode of presentation and the sensitivity pattern of isolates from blood culture were recorded. One hundred and ten case files of Salmonella paratyphi were reviewed from the medical records section and the required data (data regarding the clinical profile and antibiotic sensitivity) was collected and analyzed using SPSS version 11.5. Results: Fever was present in all patients. All the cases were sensitive for third-generation cephalosporins, and only 31.8% of the cases were sensitive for quinolones. Sensitivity towards other antibiotics in descending order was as follows: ampicillin 93.6%, chloramphenicol 91.8%, aminoglycosides 90.4% and sulphonamides 76.4%. Conclusions: Research shows that there is increasing resistance to fluoroquinolones and sensitivity to chloramphenicol. Considering the changing trend in the sensitivity pattern, the recommendations of treatment for enteric fever need to be rationalized and re-considered.
  - 2,709 658
Attitudes of Nepalese Medical Students Toward Telling Patients a Diagnosis of Cancer
Malcolm Moore, Rabin Bhandari
July-December 2012, 1(2):103-108
DOI:10.4103/2249-4863.104962  PMID:24479016
Objectives: Patient-centered communication teaching generally encourages doctors to inform patients of cancer diagnoses. In many countries, including Nepal, it is usually the patient's family that is informed. Much of the evidence about patient preferences is from western studies. The objectives of this study are: To discover the attitudes of medical students and patients in Nepal toward disclosing a cancer diagnosis; and to identify the reasons for these attitudes. Materials and Methods: A cross-sectional survey was administered to medical students and patients in a teaching hospital in Nepal. The participants were asked about their attitudes toward and reasons for informing patients of a cancer diagnosis. The data were analyzed to compare students' and patients' attitudes and to look for differences between the first and fourth year students. Results: Fifty-four percent of the students would inform a patient even if the cancer was incurable, 6% would inform only if curable, and 40% would inform the family instead. Sixty-nine percent of the students and 51% of the patients wanted a close relative informed, even if the relative was incurable (P = 0.0016). There was no significant difference between students (83%) and patients (78%) wanting to be informed of their own diagnosis. The most important reasons for students not informing the patients were fears of loss of hope and of causing depression. Conclusion: The results confirmed the diverse attitudes about informing a cancer diagnosis to patients, in Nepal. Students wanted more information for themselves than they felt patients should be given. This information could enlighten the practice of doctors in Nepal and other similar cultures, as well as guide the communication training of future doctors.
  - 2,260 336
A Case Control Study on School Dropouts in Children of Alcohol-Dependent Males Versus that in Abstainers/Social Drinkers' Children
Violet N Pinto, Rajan N Kulkarni
July-December 2012, 1(2):92-96
DOI:10.4103/2249-4863.104944  PMID:24479014
Objective: To study and compare in the children of alcohol-dependent males versus those in a socio-demographically similar control group, the occurrence of school dropouts, and to examine the link between certain factors like parental education and socioeconomic status on school dropout. Materials and Methods: This was a community-based case control study. The participants were 107 family units in both study group (alcohol-dependent male, wife, at least one child less than 14 years of age) and control group (abstainer/social drinker, wife, at least one child less than 14 years of age). It was conducted in an urban slum community in Mumbai. Interview technique was used for data collection. The study was conducted for a period of 1 year. Statistical Analysis: Using software SPSS version 17.0, percentages, Chi-square test. Results and Conclusion: The number of school dropouts was significantly higher (45.31%, P < 0.001) in the children of alcohol-dependent males as compared to 22.47% in the abstainers/social drinkers' children. In the study group, there was higher number of school dropouts among boys (52.73%, P < 0.05) as compared to girls (35.37%). There was a statistically significant association between parental illiteracy and school dropout in children in both the groups. In the control group, significantly higher number of school dropouts of socioeconomic class IV and V had dropped out as compared to those of socioeconomic class III and II.
  - 4,825 457