AGRICULTURAL MODERNISATION, VALUE OF CHILDREN AND FERTILITY BEHAVIOUR ...
AGRICULTURAL MODERNISATION, VALUE OF CHILDREN
AND FERTILITY BEHAVIOUR

P. V. MURTHY
The study examines the relationship between agricultural modernisation, costs and benefits of rearing children and
fertility behaviour of couples in rural Andhra Pradesh. Indices on economic and non-economic costs, and economic
and non-economic benefits were constructed based on scaled responses to attitude statements. Also an index on
agricultural modernisation was constructed based on important dimensions of agricultural modernisation. The couples
in the backward and developed villages differed significantly in relation to their perception on all the aspects of costs
and benefits of rearing children. It was also found that agriculturally more modern respondents scored 'high' on the
indices of economic and non-economic costs, and 'low' on the indices of economic and non-economic benefits, and
desired to have smaller number of children as compared to agriculturally less modern respondents.
Dr. P. V. Murthy is with the Population Studies Centre, S. V. University, Tirupati.
Agricultural modernisation has attracted considerable attention among social scientists
because, India is predominantly a rural economy. Nearly 80 per cent of the population live
in rural areas and about 60 per cent of the country's workforce depends on agriculture.
Agricultural modernisation leads to rise in income and to better standards of living, which
in turn, result in higher levels of schooling, increased age at marriage, more access to
health facilities, lower level of infant and child mortality and higher use of contraception. It
also leads to rise in educational aspirations, urban contacts, new tastes for modern
consumer goods and services, which raise the costs of rearing children while decreasing
their value. These finally result in the reduction of fertility. Family, size orientations including
achieved family size, ideal family size, desired family size and contraceptive use are
dependent on the costs and benefits to parents of rearing children.
Some researchers (Caldwell, 1977; Espenshade, 1977; Nag et al., 1977; Kulkarni, 1979)
have approached the problems of costs and benefits from a strictly financial point of view
and have calculated the actual costs and benefits of rearing children in their assessment
of the economic consequences of fertility. This objectives assessment of economic costs
and benefits of children is important since it affects family size decisions and fertility.
However, it is of greater importance to examine how and the extent to which parents'
perceived economic costs and benefits of children affect their family size decisions.
Besides these, there are non-economic costs, (social, psychological, cultural and so on)
and benefits. Parents' perception of the non-economic costs and benefits of children and
the extent and ways these perceptions influence family size decisions and fertility are also
of importance. Parents' perception of the costs and benefits of children and the value they
attach to these costs and benefits constitute their general attitude towards having children.
In making decisions on the size of the family, parents may not consciously consider the
various costs and benefits, but may be influenced by their attitudes that result from such
perceptions. Therefore, the present study attempts to examine the relationship between
agricultural modernisation and costs and benefits of rearing children in relation to the
desired family size.
Methodology
Two sets of villages were studied on a comparative basis for the present study. Villages
which had witnessed significant agricultural development on introduction of irrigation at

338 P. V. Murthy
least 15 years back and had taken advantage of irrigation by changing the cropping pattern
and by adopting mechanisation were labelled as agriculturally developed villages. Those
villages (selected from the same district) which did not have significant irrigation or
development through any other means were labelled as agriculturally backward villages.
A total sample of 600 couples in Chittoor district of Andhra Pradesh comprising 300 couples
from the developed villages and 300 from the backward villages were studied. The
sampling unit for the study was a household having at least one couple with the wife in the
reproductive age span of 15-44 years and one or more living children. An interview
schedule was used for data collection.
Construction of Indices
Indices on Value of Children
The perception on costs and benefits of rearing children were broadly grouped into four
categories namely economic costs, non-economic costs, economic benefits and non-
economic benefits, and in each costs and benefits, there were 10 attitudinal statements
(Appendix-I).
Perceived economic costs of rearing children were the subjective perception of the parents,
their sensitivity and attitude towards the maintenance costs of rearing children. These costs
which may induce the parents to perceive their children as a financial burden include saving
for children's education, marriage, the costs of child rearing precluding overall other
purchases, pre-occupation with child rearing as a cause for not working now, and higher
child costs as a cause for taking up employment. Perceived non-economic costs of rearing
children were the emotional and physical demands made by children on their parents, noise
and disorder in the house, extra housework, general weariness to the mother, lack of time,
sleep and worry to the parents and such other costs i.e., the adverse effects of large
number of children (4+) on the well-being of a household.
Perceived economic benefits from children were the parents' perception of instrumental
assistance and old age security benefits from children. Instrumental assistance refers to
help on the farm, business, housework and the child's contribution to the family's finances.
Perception of old age security consisted of envisaging the extent to which financial support
can be expected from the children and residence with children especially sons in old age.
Perceived non-economic benefits from children consisted of intangible factors like their
being a source of joy and happiness, a bond between husband and wife, for fulfilment of
marriage, for attaining adult status and social prestige and tangible ones like continuity of
family name and tradition, producing heirs and performing funeral rites.
It is difficult to measure and interpret variables based on individual perceptions. In order to
enhance the explanatory power of attitudinal variables (costs and benefits) a better
methodological approach using an index combining all the specific attitudinal statements
was adopted. This was considered better as measurement is bound to improve when
answers to several related questions are taken into account. Further, the analysis is much
easier to carry out when the number of variables is reduced by combining them into indices.
To measure the perceived costs and benefits of rearing children, an index was constructed
based on the scaled response to attitude statements reflecting each dimensions of the
costs and benefits of children. Each response of the attitude scale on perceived costs and
benefits of rearing children was assigned a score value - three for 'agreement', two for
'uncertainty' and one for 'disagreement'. Scoring patterns and scaled response

Agricultural Modernisation, Value of Children and Fertility Behaviour 339
dimensions used in the index construction for cumulative perceived economic and non-
economic costs and economic and non-economic benefits of rearing children were derived
from the total sum of scores assigned to the respective costs and benefits of rearing children.
Index
Score Range
Low
10-16
Medium
17-23
High
24-30
Agricultural Modernisation Index
In order to study the cumulative effect of all the independent agricultural modernisation
variables on fertility behaviour an index was developed. This index was based on ten
important agricultural modernisation dimensions such as (a) total land holding; (b) source
of irrigation; (c) system of irrigation; (d) value of the produce (rabi season); (e) value of the
produce (kharif season); (f) usage of high yielding variety seeds; (g) adoption of plant
protection measures; (h) total number of labourers hired; (i) farm assets; and (j) livestock.
Based on the composite score (the range values for each of the ten items are given in
Appendix-II) assigned to them by giving appropriate weights to their responses, the
respondents were stratified as agriculturally 'less modern', 'intermediate' and 'more modern'.
Index
Score Range
Less modern
10-21
Intermediate
22-32
More modern
33-43
Results and Discussion
In India, of the various determinants of fertility, the value of children significantly influences
family size preferences. This area of research has attracted considerable attention from
demographers because of its role in determining the actual or intended fertility behaviour
of couples. As such, the present paper examines the relationship between agricultural
modernisation, value of children (economic and non-economic costs, and economic and non-
economic benefits) and fertility behaviour.
Agricultural Modernisation, Perceived Economic Costs of Rearing Children and
Fertility Behaviour
The relationship between agricultural modernisation and the perceived economic costs of
rearing children in relation to the desired family size of the respondents is analysed in Table
1. An inverse relationship between the perceived economic costs of rearing children and
fertility may be noticed in all the agricultural modernisation groups conforming the strong
negative relationship between the perceived economic costs and fertility on the one hand,
and agricultural modernisation and fertility on the other hand.
With increase in the levels of agricultural modernisation, the proportion of respondents who
secured high score (24-30) on the index of perceived economic costs also increased and
the desired family size declined considerably. This trend may be observed in both sets of
villages. Among the respondents who were agriculturally less modernised, significantly
more proportion had secured the least score (10-16) with regard to the perceived economic
costs of children in both the backward (45 per cent) and developed (46 per cent) villages
and desired large number of children (3.72 and 3.40 in backward and developed villages
respectively) (Significant at 0.05 level).

340 P. V. Murthy
Table 1
FERTILITY BEHAVIOUR OF THE RESPONDENTS IN BACKWARD AND DEVELOPED VILLAGES BY
AGRICULTURAL MODERNISATION AND PERCEIVED ECONOMIC COSTS OF REARING CHILDREN
In contrast, among those who were agriculturally more modernised, an overwhelming
proportion of them secured the highest score (93 per cent and 94 per cent in backward and
developed villages respectively) on the index of perceived economic costs of rearing
children and desired the least number of children (2.72 and 2.35 in backward and
developed villages respectively) (Significant at 0.05 level). Even those who were
agriculturally more modernised but secured a medium score (17-23) on this index desired
less than three children as compared to agriculturally less modernised respondents.
Several students have reported that parents perceive their children to be making significant
economic contribution to the family (Caldwell, 1967, 1977; Arnold et al., 1975; Bulatao,
1975; Buripakdi, 1977). These perceptions of significant economic value were largely
concentrated in the rural areas of Asia and Africa among the lower income farmers and
agricultural labourers. A number of studies found the economic contributions of children to
be significant determinants of fertility (Kasarda, 1971; Cramer, 1975; Liberman, 1976; Cain,
1977; Nag et al., 1977; Aghajanian, 1978; Vlassoff, 1978).
Thus agricultural modernisation changes the attitude of couples towards the costs of
rearing children, which in turn, creates awareness among the respondents to desire lesser
number of children.
Agricultural Modernisation, Perceived Non-economic Costs of Rearing Children and
Fertility Behaviour
The perception on non-economic costs of rearing children is also higher among the
agriculturally more modernised respondents than the less modern. The overall trend
showed that as the perception of non-economic costs of rearing children increased, fertility
declined in all the three levels of agricultural modernity. The mean desired family size of
the respondents in the 'intermediate' and above modernity levels was lower relative to the
less modern group (Table 2).
This trend may be observed in both the backward and developed villages.

Agricultural Modernisation, Value of Children and Fertility Behaviour 341
Table 2
FERTILITY BEHAVIOUR OF THE RESPONDENTS IN BACKWARD AND DEVELOPED VILLAGES BY
AGRICULTURAL MODERNISATION AND PERCEIVED NON-ECONOMIC COSTS OF REARING CHILDREN
Considering the two groups separately, it was observed that the fertility of the respondents
with 'intermediates' and above level modernity was lower than those in the less modern
group. In addition, the mean desired family size of the respondents who scored 'medium'
(17-23) and 'high' (24-30) on the index of perceived non-economic costs of rearing children
was lower than those who scored 'low' (10-16). Similar trend was true for respondents in both
types of villages. Thus couples who were more modern and had higher perception of the
non-economic costs of rearing children opted for lower family size as against those who
were less modern and had lower perception of the non-economic costs of rearing children.
The findings reveal that differences in perception of non-economic costs of rearing children
and agricultural modernisation significantly influence fertility behaviour. These findings are
corroborated by the studies conducted in Thailand (Arnold et al., 1975), and Taiwan
(Mueller, 1972) which reported an inverse relationship between perceived costs of rearing
children and family size. Similarly, Usha Rani (1983) in her study on costs of rearing
children and other socio-economic determinants of fertility in rural Andhra Pradesh also
reported that the direct and indirect costs of rearing children were associated with a large
family size (4+ children).
Agricultural Modernisation, Perceived Economic Benefits of Rearing Children and
Fertility Behaviour
Table 3 presents the relationship between agricultural modernisation and perceived
economic benefits of rearing children in relation to the desired family size. The findings
indicated that the differences in the perceived economic benefits of rearing children
significantly influence the fertility behaviour differentially among the respondents with
different agricultural modernity levels.
In both the backward and developed villages, with increase in the level of modernisation
in agriculture, the proportion of the respondents who scored 'low' (10-16) on the index of
perceived economic benefits of rearing children also increased. The low score indicated

342 P. V. Murthy
Table 3
FERTILITY BEHAVIOUR OF THE RESPONDENTS IN BACKWARD AND DEVELOPED VILLAGES BY
AGRICULTURAL MODERNISATION AND PERCEIVED ECONOMIC BENEFITS OF REARING CHILDREN
that those who were agriculturally more advanced expected less economic benefits from
their children which had a decisive influence on the desired family size. More than three-
fourths (83 per cent) of the more modern respondents in the developed villages as against
one half (50 per cent) of them in the backward villages secured 'low' scores on perceived
economic benefits of rearing children. In contrast, the majority of the less modem
respondents (71 per cent in backward villages and 85 per cent in developed villages)
secured high scores (24-30).
In backward villages, the respondents who were more modern with regard to agriculture
and secured 'low' scores on perceived economic benefits from children, desired the lowest
number of children (2.65) as compared to those who were agriculturally less modern and
secured 'high' scores (3.50 mean desired family size) (Significant at 0.01 level) on the index
of perceived economic benefits of rearing children. This trend was more significant in the
developed villages and the corresponding figures were 2.27 and 3.34 respectively
(Significant at 0.01 level). The observed negative relationship between the perceived
economic benefits of rearing children and fertility has been established in a number of
studies (Mueller, 1972; Hoffman et al., 1973; Caldwell, 1977; Aghajanian, 1978).
Agricultural modernisation leads to less demand for child labour and reduces the economic
benefits of children which directly or indirectly influence the decision on family size couples.
Agricultural Modernisation, Perceived Non-economic Benefits of Rearing Children
and Fertility Behaviour
Significant differences in the desired family size of the agriculturally less modern and more
modern respondents in relation to their perceived non-economic benefits of rearing children
may be observed (Table 4). Among the agriculturally less modern respondents, an
overwhelming proportion of them secured 'high' scores (24-30) in both backward (89 per
cent) and developed villages (96 per cent). In contrast, among the agriculturally more
modern respondents, only 48 per cent and 29 per cent secured 'high' scores in the
backward and developed villages respectively.

Agricultural Modernisation, Value of Children and Fertility Behaviour 343
Table 4
FERTILITY BEHAVIOUR OF THE RESPONDENTS IN BACKWARD AND DEVELOPED VILLAGES BY
AGRICULTURAL MODERNISATION AND PERCEIVED NON-ECONOMIC BENEFITS OF REARING CHILDREN
In the backward villages, agriculturally less modern respondents with 'high' scores desired
0.93 children more than the more modern respondents with 'low' scores on the perceived
non-economic benefits of rearing children. The findings showed that the perceived non-
economic benefits of rearing children also proved to be a vital factor in influencing the
desired family size.
When the magnitude of perception on economic and non-economic benefits of rearing
children were considered, the non-economic benefits were found to be perceived more by
the respondents in both backward and developed villages. Even among the respondents
who were agriculturally more modern, a reasonable percentage of them perceived high non-
economic benefits of rearing children.
It is evident from the above findings that the economic betterment resulting from agricultural
modernisation leads to change in the attitudes of people with regard to value of children,
and thereby influences fertility behaviour. Similar findings were reported by Khuda (1988)
in a village in the Comilla district of Bangladesh. As a result of agricultural development
programmes, the area under mechanisation, fertiliser application, use of pesticides and the
cropped area under high yielding varieties increased considerably. It was also observed
that the age at marriage and the use of contraceptives were higher and fertility lower in the
village than in other parts of the country. Many rural families acquired new tastes for modern
consumer durables and the ownership of modern farm implements per household was
higher, the level of schooling also increased and all these resulted in decreasing the value
of children. Basu et al., (1979) studied the relationship between agricultural development
and fertility in rural Gujarat. It was found that the developed villages had a lower cumulative
fertility index than the undeveloped villages. They also found that the aspiration level of the
benefitted class had gone up significantly leading to a higher perceived cost of children and
a lowered desired family size. Arnold and Perjaranonda (1977) reported a more systematic
relationship of perceived economic utility and cost of children with fertility behaviour in
Thailand. High perceived utility of children was found to be associated with low income
farming families. They also found that economic indicates of the perceived utility and cost
of children each had a significant net effect in the expected direction on all of the

344 P. V. Murthy
fertility-related variables. The study by Victor Levy (1985) focused on the direct relation
between modernisation and changes in agriculture and the economic contribution of
children and its effect on desired family size and fertility. He examined cross sectional
evidence on differential fertility in rural Egypt, which indicated that variation in labour
contributions from children had an appreciable effect on farmers' attitude towards fertility
and actual family size. Since agriculture is the most important and major component of the
rural system which influences family size decisions significantly, the emphasis has been on
modernising this aspect.
In the rural areas, the cost of rearing children is low and the farmers with large families get
a great deal of net benefits from children. Usually children are considered very useful labour
at their early ages itself as they directly contribute to the farm output, as well as household
maintenance activities. Further, farmers with little land desire to have more sons as a
source of security in times of distress or in old age. It is obvious from the above findings
that costs and benefits of rearing children, along with agricultural modernisation influence
family size decisions.
In order to reduce fertility, it is essential to reduce the actual and perceived benefits from
having a large number of children. This may be possible partly through the modernization
of agriculture. The mechanisation and introduction of modern technology in agriculture
increases the cost of cultivation, as well as decreases the need of child labour. In order to
substantiate the increased cost of cultivation, the farmers have to reduce the cost of rearing
children which makes them limit their family size. Further, agricultural modernisation
increases the production and, thereby, the income, and cuts the economic dependency of
the parents on their son(s) during old age. In order to reduce the benefits from children,
which is more prevalent in rural areas, the farmers are to be educated by organising block
level special training camps and through adult education programmes about the
disadvantages of large families, they should also be acquainted with the availability and use
of new technologies and improved inputs.
Acknowledgement
My sincere thanks are due to Dr. D. Usha Rani, Director, Extension Studies and Dr. M. Hari, Lecturer, Department of Population Studies,
S. V. University, Tirupati for their suggestions.
APPENDIX-I
Statements on Perceived Economic Costs of Rearing Children
(a) Raising children is a heavy financial burden for most people
(b) The real financial worry about children is education
(c) Children eat very little but they are still expensive
(d) Clothing of children is a financial worry
(e) Housing is a problem when there are many children
(f) Too many children means too many divisions of property
(g) Having a lot of children will make their families less well-off
(h) No worry about daughters' marriages and their dowry
(i) Having many and frequent pregnancies means increased financial problems later on in life
(j) Occupational immobility affecting improvement in economic status (present and future)
Statements on Perceived Non-economic Costs of Rearing Children
(a) Many children mean extra work and care
(b) It is a heavy and tedious job to take care of many children
(c) Having many children is a great mental strain and loss of sleep
(d) Having many children means less leisure
(e) Having many children causes problems and disagreements between wife and husband
(f) Many children lead to loss of affection between the couple
(g) Many pregnancies result in deterioration of mother's health
(h) Too many children lead to lack of privacy (cannot be by yourself)
(i) Having many children does not permit the wife to have contacts and friendships outside the home and participate in community
development activities
(j) Many children are a restriction on social life (cannot attend marriages, parties, meetings and so on freely)

Agricultural Modernisation, Value of Children and Fertility Behaviour 345
Statements on Economic Benefits of Rearing Children
(a) Without young children's help men would find it difficult to farm
(b) Without unmarried daughters' help women would find it difficult to do their housework
(c) A good reason for having children is that they can help financially when parents are too old to work
(d) Children provide facilities required for meeting the physical needs and comforts of the parents
(e) Children inherit family property
(f) Children are wealth and welfare
(g) A man with many children has more leisure than a man with few
(h) The best property a widow can have are children
(i) More children mean large number of reliable hands to maintain the wealth
(j) More sons mean more dowries
Statements on Perceived Non-economic Benefits of Rearing Children
(a) Give and take of love and affection
(b) Enlarge kinship relation
(c) Continue family line (lineage)
(d) Perform rituals in the family
(e) A person with children is respected in the community more than a person without children
(f) One of the best things about having children is that you are never lonely
(g) Children perform funeral rites
(h) Pride in children's accomplishments
(i) Extension of social relations
(j) Increase of social prestige through children's status
APPENDIX-II
AGRICULTURAL MODERNISATION INDEX

346 P. V. Murthy
REFERENCES
Aghajanian, A.
"Fertility and family economy in the Iranian rural communities", Journal of
1978
Comparative Family Studies Vol. 9: 119.
Arnold, F. et al.,
The Value of Children: A Cross National Study, Hawaii, Honolulu: East-
1975
West Population Institute, Vol. 3.
Arnold, F. and Perjaranonda, C.
Economic Factors in Family Size Decisions in Thailand, Bangkok; Institute
1977
of Population Studies, Chulalongkorn University, WFS and SOFT Report
No. 2.
Basu, D. N. et al.,
Impact of Agricultural Development of Demographic Behaviour, New
1979
Delhi: Abhinav Publications.
Bulatao, R. A.
The Value of Children: A Cross National Study, The Philippines, Honolulu:
1975
East-West Population Institute, Vol. 2.
Buripakdi, C.
The Value of Children: A Cross National Study, Thailand, Honolulu: East-
1977
West Population Institute, Vol. 4.
Cain, M. T.
"The economic activities of children in a village in Bangladesh",
1977
Population and Development Review, 3: 201-227.
Caldwell, J. C.
"Fertility attitudes in three economically contrasting rural regions of
1967
Ghana", Economic Development and Cultural Change, Vol. 15.
Caldwell, J. C.
"The economic rationality of high fertility: An investigation illustrated with
1977
Nigerian survey data", Population Studies, 31:5-27.
Cramer, J. C.
"The opportunity costs of children and expected family size in the United
1975
States, 1968-1972", Seattle: Paper Presented at the annual meeting of
the Population Association of America.
Espenshade, T. J.
"The value and cost of children" Population Bulletin, Population
1977
Reference Bureau Inc. Vol. 32, No. 1.
Hoffman, L W. et al.,
"The value of children to parents", in James T. Fawcett (ed.),
1973
Psychological Perspective on Population, New York: Basic Books,
19-76.
Kasarda, J. D.
"Economic structure and fertility: A comparative analysis", Demography
1971
Vol. 8.
Khuda, B.
"Demographic impact of rural development in Bangladesh", in C. Vlassoff
1988
and B. Khuda (ed.), Impact of Modernisation on Development and
Demographic Behaviour: Case Studies in Seven Third World Countries,
Canada International Development Research Centre.
Kulkarni, S.
"Economic value of children", in K. Srinivasan et al, (ed.), Demography
1979
and Socio-economic Aspects of the Child in India, Bombay: Himalaya
Publishing House, 235-252
Liberman, S. S.
An Economic Approach to Differential Demographic Behaviour in Turkey,
1976
Ph. D Dissertation, Harvard University.
Mueller, E.
"Economic motives for family limitation", Population Studies,
1972
26:383-403.
Nag, M. et al.,
"Economic value of children in two peasant societies", in International
1977
Population Conference, Mexico, Vol. 1, Liege: International Union for the
Scientific Study of Population.
Usha Rani, D.
Cost of Rearing Children and other Socio-economic Determinants of
1983
Fertility, Ph.D. Dissertation, Sri Venkateswara University.
Victor Levy
"Cropping pattern mechanization, child labour and fertility behaviour in a
1985
family economy: rural Egypt", Economic Development and Cultural
Change, Vol. 33, No. 4.
Vlassoff, M.
Economic Utility of Children and Fertility in Rural India Ph.D. dissertation,
1978
Gokhale Institute of Politics and Economics, University of Poona.
The Indian Journal of Social Work, Vol. LIl, No. 3 (July 1991)

REASONS FOR NEWLY-DIAGNOSED LEPROSY PATIENTS
FAILING TO START TREATMENT

N. G. K. NAIR, R. RAMAKRISHNAN, V. SELVARAJ, L. SUNDARAMOORTHY,
B. KISHORE KUMAR AND S. RADHAKRISHNA
Following the finding that, about 30 per cent of newly-detected leprosy patients in Tamil Nadu failed to start treatment,
a sample of 1728 such patients was interviewed intensively by experienced field investigators to elicit the reasons.
Lack of knowledge about leprosy - its signs, symptoms and implications - and factors of personal inconvenience-
loss of wages, other pressing problems or ailments, the clinic being distant or its timings being unsuitable - were
identified as the two broad causes. Corrective measures are discussed.
N. G. K. Nair, R. Ramakrishnan, V. Selvaraj, L. Sundaramoorthy B. Kishore Kumar and S. Radhakrishna are with
the Institute for Research in Medical Statistics, Madras 600 031.
An operational assessment of the leprosy control programme in Tamil Nadu, based on a
representative sample of 14 randomly selected leprosy control units, identified two major
problems (Nair et al., in press). One was that, about 30 per cent of the newly-detected
cases did not even register for treatment and the other was that, among those who did,
about 60 per cent failed to collect drugs for six months or more in the first year of treatment.
A study was, therefore, initiated by us in a subsample of these control units to determine
the reasons for (a) non-registration, not so widely known phenomenon, and (b) irregularity
in drug collection, which is a chronic problem in all conditions that require long durations
of treatment. Although the study was, conducted in close cooperation with the Government
of Tamil Nadu, the personnel employed for data collection were not the programme staff
but field investigators independently recruited and trained by the Institute for Research in
Medical Statistics, Madras. This paper deals exclusively with the reasons for non-
registration for treatment.
Material and Methods
From among the 14 leprosy control units for which an operational assessment of the leprosy
control programme was undertaken by Nair et al., six were chosen which had an average
of 100 or more unregistered patients per subcentre; each subcentre covered a population
ranging from 20,000 to 30,000. From each such Unit, the subcentres previously studied (a
random sample) for the operational assessment were chosen for the present study. Within
each subcentre, villages with 10 or more leprosy cases and a minimum of two unregistered
cases at the time (as per the records maintained by the programme personnel) were
identified. A 50 per cent random sample of these villages was then selected, after
stratification by distance to the clinic. The objective was to trace and interrogate all the
unregistered patients, in each selected village.
Six field investigators with a three year diploma in Rural Sciences from the Gandhigram
Institute of Rural Health and Family Planning were employed for this study. All of them had
prior practical experience in interviewing villagers. They were initially given a detailed
orientation about the leprosy control programme by us for three days, with special emphasis
on the sensitive nature of their job. Subsequently, they were given field training for a period
of one week, using the proformae designed by us, in consultation with the State Leprosy
Officer and other programme administrators.

348 N. G. K. Nair et al.
A team consisting of two statisticians and six field investigators visited each of the six
selected control units and from the records listed out the addresses and other details such
as age, sex, type of leprosy, date of detection and deformity status of all the unregistered
patients in the selected villages. A list consisting of a total of 2394 patients belonging to 319
villages was prepared for interview, and attempts were made to trace these patients. During
the field visits, it was discovered that 57 (2.4 per cent) of the patients had died, 146 (6.1
per cent) had permanently left the village, 114 (4.8 per cent) could not be traced and 330
(13.8 per cent) could not be contacted as the house was locked. Of the remaining 1747
patients, 19 could not be interviewed, mainly because they were not cooperative. The
remaining 1728 patients were interviewed (in the case of children, who numbered 223, the
parent/close relative was interrogated) and data regarding their knowledge about the
disease, reasons for failure to register for treatment and their suggestions were recorded.
These data form the basis of this report.
Results
Characteristics of the Patients
Of the 1728 patients, 57 per cent were males; 3 per cent were infectious, 36 per cent non-
infectious but had multiple lesions and the rest had a single patch only; 6 per cent of the
patients were deformed; 85 per cent of the cases were detected by population survey.
About two-thirds of the patients were diagnosed three years before the start of the study,
30 per cent of them were living at a distance of less than two km from the clinic and 47
per cent were living at a distance of five km or more from the clinic; 56 per cent were illiterate.
Of the 1728 cases, 91 per cent were not accustomed to consult or seek advice from others
regarding their health problems. Almost all of them (98 per cent) participated in social and
other community functions. About half of them (52 per cent) had been advised to take
regular treatment, and in 98 per cent of these cases it was the leprosy worker who had
given this advice.
Knowledge of the Disease
Over 80 per cent of the patients were unaware of the cause of leprosy; three per cent
thought it was due to a poisonous bite, two per cent gave the cause as excessive sex and
two per cent said the disease was hereditary. Only four per cent gave bacterial infection
as the reason. Knowledge about treatment aspects was equally poor; only 43 per cent
believed the leprosy was curable. When asked about the consequences of not taking
regular treatment, 62 per cent stated that the disease might become worse, 54 per cent said
that deformities might develop and 45 per cent said that the disease might spread to others.
These findings indicate the need for effective health education at the community level.
Reasons for Non-Registration for Treatment
Patients who Gave a Single Reason
Among the 1728 unregistered patients, 1055 (61 per cent) gave a single reason for not
registering themselves at the nearby Government Leprosy Control Unit and starting
treatment. These reasons, summarised under seven broad groups, are given in Table 1.
Group I accounted for 385 of the patients, namely 36.5 per cent. This group failed to start
treatment basically due to the patient's ignorance of the disease or its implications. The

Newly-Diagnosed Leprosy Patients Failing to Start Treatment 349
three main reasons for not starting treatment, were 'Disbelief in the diagnosis' (11.9 per
cent), 'Belief that the disease had cured spontaneously' (13.6 per cent) and 'Disease
causes no inconvenience to daily routine' (9.3 per cent). Special health education to the
diagnosed patients could reduce this proportion.
Table 1
REASONS FOR NON-REGISTRATION, BASED ON 1055 PATIENTS WHO GAVE ONLY ONE REASON
Reason
No.
%
Group I
a) Disbelief in the diagnosis
126
11.9
b) Belief that the disease has cured spontaneously
143
13.6
c) Disease causes no inconvenience to daily routine
98
9.3
d) Unaware of implications of the disease
9
0.9
e) Not interested in starting treatment
9
0.9
Group II
a) No faith in the efficacy of treatment
9
0.9
b) Fear of side-effects
15
1.4
c) Fear of injections and drugs
7
07
d) No faith in treatment at Government clinics
14
1.3
Group III
a) Fear of loss of wages
91
8.6
b) No money for bus fare
5
0.5
c) Did not attend due to other ailments
55
5.2
d) More pressing problems
45
4.3
e) No time to attend clinic
13
1.2
f) Out of station
19
1.8
g) Clinic is far away
25
2.4
h) Clinic timings are not suitable
12
1.1
Group IV
Unaware of clinic location, dates and timings
174
16.5
Group V
Taking treatment from other sources
140
13.3
GROUP VI
a) Social stigma
11
1.0
b) Does not like to be treated along side other leprosy patients
11
1.0
Group VII
Miscellaneous
24
2.3
Total patients
1055
100.0
Misconceptions about treatment resulted in the failure to start treatment in the case 45
patients (43 per cent) in Group II. Corrective strategies and proper motivation could help
to overcome problem.
Personal inconvenience was the stated cause for failure to register for treatment in the case
of 265 patients, namely 25.1 per cent (Group III). 'Fear of loss of wages' (8.6 per cent),
'Other ailments' (5.2 per cent), 'More pressing problems' (4.3 per cent), and 'Clinic is far

350 N. G. K. Nair et al.
away' (2.4 per cent) were the major reasons in this group. In about 75 per cent of the
patients who cited 'Fear of loss of wages' as the reason, the loss would have been less
than Rs. 10/- on days they attended the clinic. Among 25 patients who complained that the
'Clinic is far away', 21 were living at a distance of five km or more from the clinic. Flexibility
in clinic timings or innovative methods for drug supply may reduce these losses.
Unawareness of the location of the clinic and its date and timings was reported as the
reason for not registering for treatment by 174 (16.5 per cent) patients (Group IV). In this
context, it may be stated that in the leprosy control programme in the rural areas, road-side
clinics are held once a month at prespecified spots, for dispensing drugs to patients. This
unawareness could be overcome by improving channels and methods of communication
with patients.
It was very revealing that 140 patients (13.3 per cent) who had not registered for treatment
at the clinic at the Government Leprosy Control Unit were, in fact, receiving treatment from
other sources (Group V). This included 113 (81 per cent) on allopathic treatment, 97 from
private practitioners and 16 from other Governmental agencies. Of the 140 patients, 59
stated that they sought treatment outside the programme because they thought that they
would receive better care and 19 because they were dissatisfied in general with
Governmental health services. Other reasons advanced were that the Government clinic
was too far away or had inconvenient timings (18 patients), fear of adverse publicity (9
patients), fear of side-effects (4 patients), and unawareness of the location of the
Governmental leprosy centre (9 patients).
Fear of social stigma and unwillingness to queue up with other patients in the leprosy clinic
were responsible for non-registration in the case of 22 patients in Group VI (2.1 per cent).
Patients who Gave Multiple Reasons
There were 673 patients who gave more than one reason for their failure to register for
treatment, the average being 2.2 reasons. Considering all 1728 unregistered patients (i.e.
including the 1055 who gave a single reason), there was a total of 2550 reasons. These
are summarised in Table 2.
Excluding the miscellaneous category, the ranking of the six groups by importance is
exactly the same in Table 2 as in Table 1, namely, Group I, Group III, Group IV, Group V,
Group II and Group VI; the corresponding percentages are also similar, being 35.1 and
36.5, 30.4 and 25.1,13.6 and 16.5,10.2 and 13.3,6.0 and 4.3, and 2.9 and 2.1, respectively.
Suggestions Made by the Patients
When field investigators enquired of each of the 1728 unregistered patients whether they
had any suggestions to make, 1030 (60 per cent) responded, 890 with one suggestion each
and the remaining with multiple suggestions. The most common suggestion, made by
nearly half the patients, was that the programme should offer to supply the drugs at home,
about 25 per cent said that the location, date and timing of the periodic leprosy clinics
should be given more publicity, six per cent suggested that financial assistance should be
provided for bus fare and compensation for wage loss and four per cent wanted the clinics
to be conducted in the village that they lived so that travel time would be minimal.
Of the 698 patients who had no suggestions to offer, 520 simply said that they were not
interested in taking treatment, while 90 expressed their intention to commence treatment
immediately.

Newly-Diagnosed Leprosy Patients Failing to Start Treatment 351
Table 2
REASONS (SINGLE OR MULTIPLE) FOR NON-REGISTRATION, GIVEN BY TOTAL OF 1728
UNREGISTERED PATIENTS
Reason
Wo.
%
Group I
a) Disbelief in the diagnosis
210
8.2
b) Belief that the disease has cured spontaneously
254
10.0
c) Disease causes no inconvenience to daily routine
340
13.3
d) Unaware of implications of the disease
39
1.5
e) Not interested in starting treatment
51
2.0
Group II
a) No faith in the efficacy of treatment
51
2.0
b) Fear of side-effects
39
1.5
c) Fear of injections and drugs
18
0.7
d) No faith in treatment at Government clinics
43
1.7
e) Treatment period is too long
2
0.1
Group III
a) Fear of loss of wages
193
7.6
b) No money for bus fare
16
0.6
c) Did not attend due to other ailments
153
6.0
d) More pressing problems
137
5.4
e) No time to attend clinic
53
2.1
f) Out of station
55
2.2
g) Clinic is far away
133
5.2
h) Clinic timings are not suitable
36
1.4
Group IV
Unaware of clinic location, dates and timings
347
13.6
Group V
Taking treatment from other sources
261
10.2
Group VI
a) Social stigma
34
1.3
b) Does not like to be treated along side other leprosy patients
40
1.6
Group VII
Miscellaneous
45
1.8
Total reasons
2550
100.0
Discussion
Failure of newly diagnosed patients to register for treatment has been identified as a serious
problem not only in a representative sample of routine leprosy control units in Tamil Nadu
(Nair et al., in press), but also in a specially established Treatment and Study Centre (at
Tirukoilur) which had extra inputs (Radhakrishna et al., 1982). These studies also
showed that the proportion unregistered was substantially higher in patients detected by
door-to-door survey of the population or periodic monitoring of family contacts than in those
who reported on their own because of symptoms or signs. It follows that the full benefits

352 N. G. K. Nair et al.
of an active case-finding programme cannot be attained unless the detection is followed by
intense efforts to bring all diagnosed cases under treatment. A study of the reasons why
patients do not register is therefore of immense interest not only to sociologists but also to
programme managers and health administrators.
It is vital to distinguish between excuses that patients may offer for non-registration and real
and substantive reasons. This can be accomplished only if the interrogators are well trained
and have had previous experience in interviewing rural patients. The present investigation
has the advantage that all six investigators employed had a Diploma in Rural Sciences from
a premier Institute of Rural Health and Family Planning at Gandhigram and were
experienced. Also, the quality of the data collected was monitored by a team of statisticians
from this Institute. In consequence, the findings of the study have special significance.
The study reveals that lack of knowledge regarding the disease (symptoms, signs,
implications) and factors of personal inconvenience such as loss of wages, other ailments
or pressing problems, distant clinics or unsuitable timings are the two broad causes for non-
registration. Intensive health education at the community level and improved operational
efficiency of the programme (such as proximate clinics, flexible timings, limited financial
assistance for, say, bus fare) can net more cases for the treatment programme, and this
should be a matter of high priority, especially with the availability nowadays of very efficient
multi-drug therapy for leprosy.
It is significant that 13 per cent of the unregistered patients were actually receiving
treatment from other sources, mostly private practitioners of allopathy and also, that only
one per cent of the patients gave fear of social stigma as the reason for not commencing
treatment. This is rather surprising because leprosy continues to be a disease with social
ramifications, but we gathered from our discussions with the field staff that, the majority of
patients were not clearly aware that what they had was leprosy. We also understood that
local programme managers had instructed the Leprosy Inspectors not to explicitly tell
patients that they had leprosy for fear of worrying them unduly with the social
consequences. Finally, it is unfortunate that as many as 520 (30 per cent) of the
unregistered patients stated blandly that they were not interested in commencing treatment,
and that they had no suggestions or comments whatsoever about the programme. This
group represents a hard core and may need to be tackled more intensively by the
programme personnel.
Acknowledgement
We are grateful to the Deputy Director (Leprosy), Government of Tamil Nadu for his assistance in conducting this study, and to the field
investigators for their enthusiastic cooperation.
REFERENCES
Nair N.G.K., Radhakrishna, S.,
"Some indices pertaining to the Leprosy Control Programme in Tamil
Ramakrishnan, R. and Sreenivas, V.
Nadu, based on data from a random sample of fourteen Government
(in press)
control units", Indian Journal of Medical Research
Radhakrishna, S., Christian, M. and
"A 20-year study of the Leprosy Control Programme at the Government
Nair, N.G. K.
Leprosy Treatment and Study Centre at Tirukoilur in South India", Indian
1982
Journal of Medical Research, Vol. 76, 18-35.
The Indian Journal of Social Work, Vol. LII, No. 3 (July 1991)