Qudsia Anjum  ( Departments of Family Medicine, Ziauddin Medical University, Karachi. )
Ejaz Alam  ( Departments of Family Medicine, Ziauddin Medical University, Karachi. )
Jawed Usman  ( Departments of Family Medicine, Ziauddin Medical University, Karachi. )
Shazia Shaikh  ( Departments of Family Medicine, Ziauddin Medical University, Karachi. )
Yousuf Ahmed  ( Departments of Family Medicine, Ziauddin Medical University, Karachi. )
Raza Rizvi  ( Departments of Neurosurgery , Ziauddin Medical University, Karachi. )

Pakistan is a developing country with limited resources; the expenditure on health is 0.7% of the total budget. 1 The distribution of health care is complex with major burden on tertiary care centers. The demographic variation of disease is never been taken into consideration when national health policies are made, therefore, tertiary care centers receive the greater proportion of the health budget. 1

Less than one sixth of patients utilize the government health facilities, leaving the burden on private clinics and hospitals. The average cost of health care was

4% of the total income in the urban and 5% in the rural areas. In both the areas, this constituted over 7% of the monthly household income of the poorest. 2

Studies had been conducted highlighting the morbidity patterns presented at the primary health care centers in association with the socio-demographic characteristics. A comparative study of Pakistani population to the Americans showed that the Pakistanis have a higher rate of under nutrition and an approximately equal rate of hypertension. There are urban / rural differences and economic gradients in indicators of under nutrition and risk factors for heart disease and cancers. 3 Another study showed that the Basic Health Units presented a better coverage for the infants. 4 This information is an important part of clinical epidemiology and can be of great value for educators and health care planners. 5

The International Classification of Diseases (ICD) coding is one of the reliable methods for analyzing and comparing epidemiological data between countries, parts of a country, levels of health care systems and different periods of time. An international study modified the coding system into broader categories and presented ten most common diseases at a primary care setting. 6

The objective of this paper is to identify the morbidity pattern according to age, gender and seasonal variation using the ICD coding and the utilization of Primary Health Care (PHC) center services in a demographically defined community.

The data collected from 2001-2003 was analyzed using the International Classification of Diseases-10 (ICD-10) coding for identifying the morbidity patterns presenting at the Primary Health Care Center. The age and gender distribution of the patients and the seasonal variation of few diseases were noted. Only the residents of the area visiting the center for preventive or curative services were included. Patients visiting for promotive services or living outside the defined area were excluded.

The team comprised of a male and a female medical officer, dispenser and trained community volunteers working six days a week. The consultants visited the center three days a week including a pediatrician, obstetrician and family physicians.

A structured performa was designed to enter the age, gender, disease and ICD codes. The faculty was trained for using the coding system. Trained personnel entered the data into the computer daily. The faculty members checked the performa for coding before entry.

The data entry and analysis was done in Epi-info 6 and frequencies were calculated for age, gender, ICD coding and the seasonal variation.

A total of 13,519 patients visited the PHC during three-year period. Only the first visit of the patients was taken into analysis, the follow-up visits were excluded. On an average, 376 patients were seen during a month with male to female ratio of 1:2. The males to female ratio for pediatric age group (up to 14 years) was almost equal (1:1). The reproductive age group showed a male female ratio of 1:7, and for 45 years and above also the ratio of females was higher (1:4).

The diseases coded according to ICD were compressed into categories for ease of analysis as shown in Table. The most common diseases presented belonged to the respiratory system followed by infections or parasitic infestations and diseases of the reproductive system.

The women presented for first visit of antenatal check up were 960 out of 4614 women of reproductive age group. Among the adult population, 391 (6%) presented with hypertension, 64 (1%) were Type 2 diabetics and 86 (1.3%) were asthmatics. The paediatric population analysis showed that 918 (13%) had upper respiratory infections and 1339 (19%) had diarrhoea.

The seasonal variation was analyzed for a few diseases like respiratory infections and diarrhea. Only the analysis of pediatric population for seasonal variation is shown in Figures 1 and 2. For children up to 5 years, the peak incidence of upper respiratory infections was seen in February, March and April whereas for diarrhoea during the months of June and August. Children 6 to 14 years of age showed peak for upper respiratory infections and diarrhoea during June and August respectively.

The results of this study are consistent with the studies done in other parts of the world. An international study regarding the utilization of primary health care center revealed that acute respiratory infections were the commonest to be reported followed by gastrointestinal problem. 7 Another study done in Pakistan using the ICD coding showed similar results, ranking respiratory diseases as the most common followed by infections, parasitic infestations, diseases of the skin and those of the nervous system. 8 A multicenter study identifying health problems in family practice showed that the most common problems were hypertension, upper respiratory tract infections, non-articular rheumatism, accidents and mental disorders. 5 Another study of the morbidity patterns at primary health care center revealed that the reason for frequently attending clinics was musculo skeletal problems. 9 A study done on adolescents also showed upper respiratory tract infections to be the most common presentations at a primary health care center. 10

Studies of pediatric population identified the most important group of diseases to be respiratory diseases, diarrhoea, skin problems, other infectious and parasitic diseases among infants and children less than five years of age. 4,11,12 Another study showed that dental caries, skin and hair parasites, and respiratory tract infections topped the health problems among children, whereas for adults the predominant diseases were hypertension, diabetes and asthma. 13 Studies of the geriatric population found that hypertension was the most common disorder, followed by respiratory, musculoskeletal and eye diseases. 14,15

Problem oriented medical records from health centers, computerized in a uniform standardized way, can give extensive information about the content and burden of health problems in family practice and presumably public health. The results of this study are valuable because the population (the denominator) and the geographic study area are well defined.

1. Annual report of Director General Health 2000-2001. Bio-Statistics section, Primary Health Care Cell. Islamabad: Ministry of Health, 2001.

2. Karim MS. Disease pattern, health service utilization and cost of treatment in Pakistan. J Pak Med Assoc 1993;43:159-64.

3. Pappas G, Akhtar T, Gergen PJ, Hadden WC, Khan AQ. Health status of the Pakistani population: a health profile and comparison with the United States. Am J Public Health 2001;91:93-8.

4. Escuder MM, da Silva NN, Pereira JC, Puccini RF, Herrman AA. Assessing morbidity in the paediatric community. Rev Saude Publica 1999;33:349-57.

5. Njalsson T, Sigurdsson JA, McAuley RG. Health Problems in family practice. An Iceland mullticentre study. Scand J Prim Health Care 1996;14:4-12.

6. Parnanen H, Kumpusalo E, Takala J. Primary health care ICD - a tool for general practice research. Int J Health Plann Manage 2000;15:133-48.

7. Al-Sharif AI, Al-Khalid YM, Al-Shahrani AM. Utilization of primary health care during summer. Saudi Med J 2000;21:376-8.

8. Suleman M. Patterns of health-care utilization and morbidity in a rural community near Lahore, Pakistan. Ann Trop Med Parasitol 1996;90:79-85.

9. Jyvasjarvi S, Keinanen-Kiukaanniemi S, Vaisanen E, Larivaara P, Kivela SL. Frequent attenders in a Finnish health centre: morbidity and reasons for encounter. Scand J Prim Health Care 1998;16:141-8.

10. Al-Eissa EI. The morbidity pattern among adolescents visiting primary health care centers. Saudi Med J 2000;21:934-7.

11. Muhe L, Byass P, Freij L, Sandstrom A, Wall S. A one-year community study of under-fives in rural Ethiopia: patterns of morbidity and public health risk factors. Public Health 1995;109:99-109.

12. Childhood morbidity and treatment pattern at the multipurpose health centre, Ilesa, Nigeria. Sule SS. Niger J Med. 2003;12:145-9.

13. Adib SM, Nuwayhid I, hamadeh GN. Most common diseases treated in primary health care facilities in Lebanon. J Med Liban 1995;43:17-22.

14. Prakash R, Choudhary SK, Singh US. A study of morbidity pattern among geriatric population in an urban area of Udaipur Rajasthan. Indian J Comm Med 2004;29:35-40.

15. Ogunniyi A, Baiyewu O, Gureje O, Hall KS, Unverzagt FW, Oluwole SA, et al. Morbidity pattern in a sample of elderly Nigerians resident in Idikan community, Ibadan. West Afr J Med 2001;20:227-31.

Objective: To identify the morbidity pattern according to age, gender and seasonal variation using the ICD coding and the utilization of Primary Health Care (PHC) center services in a demographically defined community.

Methods: The data collected from 2001-2003 was analyzed using the International Classification of Diseases - 10 (ICD-10) coding for identifying the morbidity patterns presenting at the PHC Center. The age and gender distribution of the patients and the seasonal variation of few diseases were noted. Only the residents of the area visiting the center for preventive or curative services were included. A structured performa was designed to enter the age, gender, disease and ICD codes. The faculty was trained for using the coding system.

Results: A total of 13,519 patients visited the PHC during three-year period. On an average, 376 patients were seen during a month with male to female ratio of 1:2. The most common diseases presented belong to the respiratory system, followed by infections or parasitic infestations and diseases of the reproductive system. The women presented for first visit of antenatal check up were 960 out of 4614 women of reproductive age group. Among the adult population, 391 (6%) presented with hypertension, 64 (1%) were Type 2 diabetics and 86 (1.3%) were asthmatics. The paediatric population analysis showed that 918 (13%) had upper respiratory infections and 1339 (19%) had diarrhoea.

Conclusion: Problem oriented medical records from health centers, computerized in a uniform standardized way, can give extensive information about the content and burden of health problems in family practice and presumably public health (JPMA 56:13;2006).