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Original Article

Prevalence of Mental Retardation in Urban and Rural Populations

of the Goiter Zone in Northwest India
Shailja Sharma1, Sunil Kumar Raina2, Ashok Kumar Bhardwaj3, Sanjeev Chaudhary4, Vipasha Kashyap5,
Vishav Chander2
1

Resident, 2Associate Professor, 3Professor, 5Clinical Psychologist, Departments of Community Medicine and 4Professor, Paediatrics,
Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Abstract
Background: The existence of an endemic goiter belt along the southern slopes of the Himalayas has been known
for a long time. Prevalence of neonatal hypothyroidism is high and there has been little work on the prevalence of
mental retardation in this part of India. Objective: The study was conducted with the aim to know the prevalence of
mental retardation in the urban and rural populations of Himachal Pradesh, India and to generate a hypothesis on the
differential distribution (geographical) of mental retardation. Methods: This cross-sectional study was conducted in the
rural and urban areas of the district of Kangra, Himachal Pradesh, India among children of 1-10 years of age. In the
rst phase, the children in the age group of 1-10 years were screened for mental retardation using the Ten Questions
Screen, whereas in the second phase the suspects were evaluated clinically. Results: The prevalence of mental
retardation was found to be 1.71% in the study population with higher prevalence (3.3%) in the 73-120 months age
group. The prevalence was higher among the males in all study populations [rural: 1.9%, urban (nonslum): 1.6%, and
urban slum: 7.14%). The prevalence was similar among the urban (nonslum) (1.75%) and rural (1.11%) populations,
whereas it was higher (4%) in the urban slum population. A prevalence of 2% was seen in families from the lower
middle class and 1.8% among families from the lower class in the rural population, whereas a prevalence of 2% was
seen among lower middle class families of urban (nonslum) areas. Conclusion: The prevalence of mental retardation
was higher in our study than in other parts of the country. The study concludes with the hypothesis that the prevalence
of mental retardation is differentially distributed geographically with socioeconomic factors being important predictors.

Keywords: Goiter zone, India, mental retardation, prevalence

Introduction
The World Health Organization (WHO) estimates that
globally over 450 million people suffer from mental
disorders. Currently, mental and behavioral disorders
Corresponding Author: Dr. Sunil Kumar Raina,
Department of Community Medicine, Dr. Rajendra Prasad
Government Medical College (RPGMC), Tanda, Kangra,
Himachal Pradesh, India.
E-mail: ojasrainasunil@yahoo.co.in

Access this article online

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Website: www.ijph.in
DOI: 10.4103/0019-557X.184545
PMID: ***

account for 12% of the global burden of disease. This is

likely to increase to 15% by 2020. The major proportions
of mental disorders come from low- and middle-income
countries. The problem is further complicated by a lack of
adequate trained manpower and a low priority of mental
health in health policy.1
The etiologies of mental retardation are multiple, and
prevalence can be influenced by social, economic,
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Cite this article as: Sharma S, Raina SK, Bhardwaj AK, Chaudhary S,
Kashyap V, Chander V. Prevalence of mental retardation in urban and rural
populations of the goiter zone in Northwest India. Indian J Public Health
2016;60:131-7.

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132

Sharma, et al.: Prevalence of mental retardation in the goiter zone of Northwest India

cultural, racial, ethnic, and other environmental factors

including the demographics of age and gender. Various
studies have consistently found the prevalence of mental
retardation to be associated with a low socioeconomic
status.2
On the basis of the nature of the factors, causes may be
classied as environmental and genetic. Environmental
causes can affect a child via pre- and postnatal exposures.
There are numerous environmental factors that often
contribute to mental retardation. Toxins such as lead and
mercury affect mental health. Iodine deciency affecting
about 2 billion people all over the world is the leading
preventable cause of mental disability in areas of the
developing world where iodine deciency is endemic.
Lack of adequate availability of iodine from the mother
restricts the growth of the brain of the fetus and leads
to a condition called neonatal hypothyroidism. In India,
about 150 million people are at risk of iodine deciency
disorder, 54 million have goiter, and 2.2 million suffer
from cretinism.3
Endemic goiter exists in an extensive belt along the
southern slopes of the Himalayas and this has been known
for a considerable time. The goiter belt covers 2,400 km
and is one of the most intense areas of endemic disease.
Faced with the goiter problem of a great magnitude, the
Government of India in collaboration with the Government
of Punjab and the Indian Council of Medical Research
(ICMR) decided in 1954 to undertake a systematic eld
experiment to demonstrate the effectiveness of iodine
when added in small physiological doses as a supplement
to the common salt habitually consumed by the people
in endemic areas in the prevention of goiter (the Kangra
valley study).4
The present study has been conducted with the aim
to know the prevalence of mental retardation in the
urban and rural populations of Himachal Pradesh and
to generate a hypothesis on the differential distribution
(geographical) of mental retardation in the goiter belt of
the sub-Himalayan region.

Materials and Methods

This study was conducted in the urban, rural, and
slum populations of the district of Kangra in Himachal
Pradesh, India. For the purpose of the study, nine wards
of Kangra town with a population of 9,528, along with
its slum population were considered for the urban

(nonslum and slum) population while Shahpur block

with a population of 136,000 and Nagrota Bagwan block
with a population of 115,767 were considered for the
rural population. The study was conducted for a period
of 1 year from January 1, 2013 to December 31, 2013.
The study population included children in the age group
of 1-10 years of age from the selected areas. The study
was approved by the institution ethics committee.
The sample size calculation was based on WHO guidelines
for population-based assessment of disabilities. In
the WHO publication Development of indicators for
monitoring progress towards health for all by the year
2000, a sample size of 1,000 is recommended for
covering all disabilities. But if the survey is aimed at
assessing specic disorders, such as mental retardation,
a sample size of 5,000 is suggested.5 To achieve the
most accurate estimates, it is advisable to conduct a
house-to-house survey in three areas: one urban slum
(including urban slum areas around the capital or any
other major city) and two rural areas, one that is relatively
economically prosperous and one that is poor.6
Keeping this in view, a sample of 5,000 children was
planned from the urban area including its urban slum
area and rural areas (Shahpur and Nagrota Bagwan areas)
as mentioned earlier. However, to round off the sample
distribution in these areas, a total of 5,300 children who
were 1-10 years of age (500 from urban and 4,800 from
two rural areas) were included in the study. The study
population of 5,300 was divided in a proportion of 90%
and 10% between the rural and urban areas, respectively,
in accordance with the demographic distribution prevalent
in Himachal Pradesh.7 The study design comprised a
stratied two-stage sampling. The design was similar in
rural and urban areas.

Urban area
Kangra town is distributed around nine urban wards and
has one slum area attached to it. The wards and the slum
area formed the primary sampling unit, and the children
the secondary unit. Fifty children from each of the nine
wards of Kangra town (described as urban nonslum and
hereafter referred to as urban area) and the urban slum area
(hereafter referred to as slum area) were included in the
study, giving us the required sample size of 500 children.

Rural area
Samples were derived from two blocks: Nagrota Bagwan
and Shahpur. The villages formed the primary sampling

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Sharma, et al.: Prevalence of mental retardation in the goiter zone of Northwest India

unit, and the children the secondary unit. The 30-cluster

technique primarily used to estimate immunization
coverage was used as a strategy to pick up the primary
sampling units. Before the sampling began, the population
was divided into a complete set of nonoverlapping
subpopulations (clusters) with a defined geography
(villages). After this, 30 of these clusters were sampled
with probability proportionate to the size (PPS) of the
population in the cluster. A cluster of 30 villages was
taken from each block. About 80 children taken from
each cluster were included in the study to complete a
sample requirement of 2,400 children from each block.
In case of insufcient number of children in a single
cluster, children in the adjoining village were included.
Parental permission was sought before including children
up to 7 years of age in the study after ensuring the
following:
1. The process conducted in a manner and location that
ensured the participants privacy.
2. Giving adequate information about the study in a
language understandable to the participant.
3. Providing adequate opportunity for the participant
to consider all options.
4. Responding to the participants questions.
5. Ensuring that the participant understood the
information provided.
6. Obtaining the participants voluntary agreement to
participate.
7. Continuing to provide information as required by the
participant or the research.
In children above 7 years of age, assent from children in
addition to parental permission after fullling the above
criteria was obtained.
Thus, from each village and urban ward children less than
10 years of age were selected. Once the children were
identied, an evaluation was performed. The evaluation
was conducted in two phases:
1. Screening phase, and
2. Clinical evaluation.

Phase I (screening phase)

Information about the child was preferably sought from
the parents of the child. If the parents were not available,
the same information was collected from any adult
respondent present in the house at that time. After the
beneciaries were identied, a screening questionnaire
was administered to identify children suspected of

133

mental retardation. The screening questionnaire had been

prepared in accordance with the Ten Questions Screen for
the disability previously used in similar studies.8
The questionnaire was translated into the local language
and administered during a personal interview after
establishing the validity of the translated version by a
reiterative technique with the parent or guardian. The
details are provided elsewhere.9
The Ten Questions Screen is a brief questionnaire
designed to screen serious cognitive, motor, seizure,
vision, and hearing disabilities among young children in
surveys of a culturally diverse population.2,8-12 Five of the
questions focus specically on cognitive development,
two questions relate to movement disability, and one
question each focuses on seizures, vision, and hearing,
respectively.
Using a global rather than a disability-specific
interpretation of the ten questions,10 a child was considered
positive for any disability if a response to any one question
indicated potential disability. Using the global denition,
the Ten Questions Screen has been shown to have good
reliability10 and validity (sensitivity 85%) for detecting
severe neurodevelopmental disabilities.11 In addition to
the Ten Questions Screen, a structured pro forma was
administered to collect demographic information about
each child and his/her household. In addition, inquiries
on details of the socioeconomic status of the child were
made using the Uday Pareek scale in the rural areas and
Kuppuswamy scale in the urban areas.

Phase II (clinical evaluation)

All children who screened positive were referred for
clinical evaluations. Clinical evaluation was performed
(without the knowledge of the screening result) by a
pediatrician. The diagnosis of mental retardation was
made after psychological assessment based on nonverbal
scales from the 1985 revision of the Stanford-Binet
intelligence test.13 The assessment of mental retardation
was also based on the childs developmental history and
a structured observation of the childs functioning in
language, response to instructions, and his or her ability
in motor skills and behavior. The classication of a child
as mentally retarded implied signicantly sub average
intellectual functioning existing concurrently with related
limitations in two or more of the following applicable
adaptive skill areas with such limitations manifested
before age 18:14 communication, self-care, home living,

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Sharma, et al.: Prevalence of mental retardation in the goiter zone of Northwest India

134

social skills, community use, self-direction, health and

safety, functional academics, leisure, and work.

Results
Ninety-one children out of a total of 5,300 turned out
to be suffering from mental retardation, giving an
overall prevalence of 1.71%. Mental retardation was
6.82 times more among children 73-120 months of age
as compared to 12-36 months [odds ratio (OR) = 6.82;
condence interval (CI) = 2.96-15.69) and the association
was highly signicant (P = 0.001) [Table 1]. Mental
retardation was more among males in the rural, urban,
and the slum populations as compared to the female
population [Table 2]. The difference however, was not
found to be statistically signicant [Table 3]. Amongst
the 500 children examined in Kangra town, the highest
prevalence of 1.4% was seen in the age group of
37-72 months with an OR of 1.5 (CI = 0.136-17.05)
although the association was not statistically signicant
(P = 0.73).
A total of 50 children were screened in the adjoining slum
area of Kangra town. Out of them, only two were mentally
retarded. Both were males. One was 12-36 months of age,
whereas the other was in the age group of 37-72 months.
All the families screened belonged to the upper lower
class.
Table 1: Agewise prevalence of mental retardation in the study
population
Age
Mental
No mental
Total
(months) retardation N (%) retardation N (%)
Rural
12-36
37-72
73-120
Urban
12-36
37-72
73-120
Slum
12-36
37-72

OR (CI)

6 (0.5)
14 (0.8)
64 (3.3)

1,220 (99.5)
1,641 (99.2)
1,855 (96.7)

1,226
Reference
1,655 1.73 (0.67-4.49)
1,919 6.82 (2.96-15.69)

1 (0.9)
2 (1.4)
2 (1.0)

106 (91.1)
139 (98.6)
200 (99)

107
Ref
141 1.5 (0.136-17.05)
202 1.06 (0.09-11.85)

1 (3.1)
1 (5.5)

31 (96.9)
17 (94.5)

32
18

Table 4 provided details on the prevalence of mental

retardation among participants belonging to different
socioeconomic classes. The difference was statistically
signicant in the rural area only.

Discussion
Ninety-one children out of a total of 5,300 turned out to
be suffering from mental retardation, giving an overall
prevalence of 1.71%. However, there was a clear-cut
difference in the prevalence of mental retardation
among different geographically located population
groups. Globally, the prevalence of mental retardation
has a variance of 1-3%.15 The prevalence rate in the
Metropolitan Atlanta Developmental Disability Study
conducted from 1985 to 1987 was reported to be 12 per
1,000 in children of 10 years of age. In a critical review
of the literature published in 1997, 43 studies conducted
across the world and published between 1981 and 1995
were analyzed, reporting a prevalence of 3.8 per 1,000
(for severe mental retardation).16 The present study did
not specify the severity of the disease while diagnosing
mental retardation. However, the Ten Questions Screen
that was used in the study generally detects cases with
severe mental retardation.
In India, the National Sample Survey Organisation
(NSSO) showed a prevalence of 0.95%.17 Raina et al.
in a study in Jammu and Kashmir reported a prevalence
of 0.70%18 and Ganguly et al. in their review of studies
on mental disorders in India, reported a prevalence of
0.53%.19
Mental retardation in the present study was higher (3.3%)
among children in the age group of 73-120 months as
compared to the younger age groups. Similar results were
seen in several other population-based studies conducted
on children who were 5-19 years of age where a higher
prevalence of mental retardation was seen in the older
age group.16 The reason for such a trend could possibly
be attributed to the difculty in diagnosis at an early age.
When these mentally retarded children attend school,
they are likely to be discovered by their teachers. 20

Table 2: Genderwise prevalence of mental retardation in the study population

Gender

Male
Female

Rural

Urban

Slum

Mental
retardation N (%)

No mental
retardation N (%)

Total

Mental
retardation N (%)

No mental
retardation N (%)

Total

Mental
retardation N (%)

No mental
retardation N (%)

Total

47 (1.9)
37 (1.6)

2412 (98.1)
2304 (98.4)

2459
2341

4 (1.6)
1 (0.5)

240 (98.4)
205 (99.5)

244
206

2 (7.1)
0

26 (22.9)
22 (100)

28
22

The gures in parenthesis are percentages

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Table 3: Association between the prevalence of mental

retardation and gender
Gender
Male
Female

Rural (OR/CI)

Urban (OR/CI)

Signicance

1.21 (0.79-1.88)
P=0.38
Reference

1.77 (0.29-10.70)
P=0.53

Not signicant

Table 4: Socioeconomic status and prevalence of mental

retardation
SES
Rural
Middle class
Lower middle
class
Lower class
Urban
Upper middle
class
Lower middle
class
Upper lower
Lower class

Mental
retardation

Total

OR

P value

19 (1.1)
61 (2.0)

1707
3,008

Ref
0.549 (0.32-0.91)

0.02

4 (4.7)

85

0.237 (0.082-0.680)

0.004

2 (0.8)

245

Ref

2 (2.4)

83

2.95 (0.42-20.65)

0.68

1 (1.4)

69
1

0.560 (0.50-6.26)

0.63

The gures in parenthesis are percentages

Such children were also noticed when they approached

the health facility for specialty services such as visiting
the doctor or making a disability certicate for availing
concessions.
The prevalence of mental retardation in the present
study was higher among males in all the three study
populations, i.e., the rural (1.9%), urban (1.6%), and
slum (7.14%) populations. Increased prevalence among
the male children in the present study was in accordance
with various studies conducted globally. In their study
in Bangladesh, Islam et al. reported a higher prevalence
among male children21 just as Durkin et al. reported
similar ndings in Karachi, Pakistan.8 In a study on
the etiological spectrum of mental retardation and
developmental delays, Aggarwal et al. have stated that
increase in the prevalence among male children could
probably be due to underreporting of mental retardation
in female children.22 Carolyn et al. in an analysis of
the data from the Metropolitan Atlanta Developmental
Disabilities Study have reported a higher prevalence
of mental retardation among boys. However, they too
attributed this male gender predominance among those
affected to sex-based difference in treatment and referral
pattern, and to the increased presence of sex-linked
disorders such as the fragile X syndrome in boys.23
Durkin et al. in their study in Karachi, Pakistan have
reported a higher prevalence of mental retardation in the

135

rural areas as compared to urban areas.8 A signicant

association was observed between mental retardation
and the socioeconomic status of the family of the
study population. The highest prevalence was seen
among children from the lower middle class (2%)
and lower class (1.8%) in the rural areas and lower
middle class in the urban areas (2%). Children from
economically disadvantaged families tend to score
lower on intelligence quotient (IQ) tests than children
from afuent families. Various factors in the childs
environment due to the socioeconomic condition of
the family contribute to the intellectual development
of the child.20
Carolyn et al. in their work on sociodemographic risk
factors for mental retardation have stated that isolated
mental retardation rarely occurs in children from a higher
socioeconomic status unless the child has sustained some
biological damage, and that isolated mental retardation is
associated with the economic condition of the family.21
In their work on prevalence of mental retardation among
children in Metropolitan Atlanta Murphy et al. have
mentioned the effects of socioeconomic factors on
the higher prevalence of mental retardation among
Black children.24 Some studies mentioned the sensory
deprivation of children from poor backgrounds due to
lack of toys to play with and fewer objects of any kind
to stimulate their imagination. Lead poisoning from
eating paint chips is a condition exclusively associated
with poverty. The higher rate of birth defects and other
conditions associated with brain damage are present in
the poorer sections.20
Mental retardation has a vast spectrum of etiologies
ranging from genetic, environmental, and metabolic.
Iodine deciency forms one of the major preventable
causes of mental retardation. In a study conducted
in the district of Kangra, the prevalence of neonatal
hypothyroidism was found to be 4.4%,25 which is much
higher than the national prevalence which ranges from
1.6 per 1,000 to 1 in 3,400.26 This high prevalence of
congenital hypothyroidism could be a reason for the
increased mental retardation in the district.
Further, poor diet, poor health practices, and unhygienic
housing conditions may lead to mental retardation. These
conditions are often associated with lower socioeconomic
status and since 62% of our study population belongs to
the lower middle class it could account for the increased
prevalence of mental retardation.

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136

The present study also revealed ndings with a variation in

the prevalence of mental retardation among the different
population groups studied. What exactly accounts for
this differential distribution across populations? Adverse
social outcomes such as social disengagement, differences
in lifestyle, differences in health awareness and health
care delivery systems, differences in geographical
distribution of genetic and environmental risks, and
nutritional status may be the factors contributing to this
difference. Further, this difference in mental retardation
is similar to our ndings on differential distribution of
other disorders such as dementia.27

8.

9.

10.

Probably the future research on mental retardation should

focus on understanding the cause for its differential
prevalence across populations.

11.

Conclusions

12.

In addition to the probable cause of congenital

hypothyroidism, chromosomal and metabolic abnormalities
maybe the reason for mental retardation. The study
concludes with the hypothesis that the prevalence of mental
retardation is differentially distributed geographically with
socioeconomic factors being important predictors.

13.

14.

Financial support and sponsorship

Nil.
15.

Conflicts of interest
There are no conicts of interest.

16.

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Fellowship Award to Life Members

Nominations are invited from Life Members of Indian Public Health Association for the Award of Fellowship.
The prescribed Fellowship application form is available at the IPHA website www.iphaonline.org
The nominations should reach the IPHA HQ Ofce, at 110, C.R. Avenue, Kolkata 700073 by 30th September 2016.
Nominations should be accompanied by relevant supporting documents (details available at website www.
iphaonline.org
Sd/- Dr Sanghamitra Ghosh
Secretary General, IPHA
Indian Journal of Public Health, Volume 60, Issue 2, April-June, 2016