Volume 12 Number 1 Jan-March 2021 Indian Journal of Public Health Research & Development EXECUTIVE EDITOR Vidya Surwade Associate Professor, Dr Baba Saheb Ambedkar, Medical College & Hospital, Rohinee, Delhi
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Indian Journal of Public Health Research & Development
www.ijphrd.com Contents Volume 12, Number 1 January-March 2021
1. Utilization of Health Care Services among the Farmers of Rural Field Practice Area of Department of Community Medicine KIMS, Hubballi: A Cross Sectional Study ...... 1 Anjana R Joshi , Dattatraya D Bant
2. The Role of Serum LDH Level an Early Marker and Prognostic Indicator for Megaloblastic Anemia in Children ...... 7 Ankit Gupta, Ravanagomagan, R.S.Sethi
3. Cog-y Balance Test: Validity and Reliability for Fall Prediction in Community Dwelling Elders ...... 13 Ankita Gosai, Dhruvkumar Dave
4. Water, Sanitation and Hygiene Challenges Faced in India in COVID-19 Prevention: A literature Review ...... 22 Anne Praveena Rani, Florence Elizabeth R, Mahesh Maria Nathan
5. Assess the Effectivness of Training Programme on Auxiliary Nurse Midwives Related to New Born Care ...... 26 Anu Gauba , Maharaj Singh
6. A Cross Sectional Study on Tobacco usage among rural adult population of Davangere, South India ..30 Arun Daniel J, Madonna J Dsouza, Pragati Chavan
7. Hidden Subjective Aspects in the Law of Diminishing Marginal Utility: The Initial Bump and Limitations of Neuroeconomics ...... 33 Asima Tripathy, Rajat Kumar Pradhan
8. Assess the Awareness and Perception Regarding Birthing Process among Pregnant Women Residing in Tribal Areas of Bhandardara...... 40 Bharti Satish Weljale
9. COVID-19 Essentials: Preparing Health Care Professionals before the Pandemic Spread in Kerala, India ...... 47 Chithra Valsan, Ronnie Thomas, Joshi Paul Chirayath, Varghese P R, Praveenlal Kuttichira
10. Study on the Prevalence of Tuberculosis in HIV Seropositive patients attending the ART Centre, KIMS, Hubli ...... 53 Dattatraya D Bant, Raghavendra D II 11. Impact of COVID-19 Pandemic on Mental Health and Effects of a Sense of Verdict of Selected College Students in Nepal, Nigeria and India...... 60 Deepak Vishwakarma, Rejoice Puthuchira Ravi, Ebbie Thomas
12. COVID 19 Awareness and its Impact on Periodontal Practice among Dental Care Professionals in Southern States of India- A Cross Sectional Survey...... 69 Lakshmi Ramachandran, Janani Karthikeyan, Santo Grace Umesh, Anupama Tadepalli, Harinath Parthasarathy, Dhayanand John Victor
13. A Study to Assess the Health Seeking Behavior and General Health Problems among Female Patients Visiting A Rural Health Center in Ambikapur, Surguja District in Chhattisgarh, India...... 80 Manish A. Prasad, Deepti Chandrakar
14. Development of ICF based Assessment of Disability in Diabetic Neuropathy (ADDiN)...... 87 Manoj Abraham M , Ennapadam S Krishnamoorthy, Vivek Misra, B
15. Prevalence and Profile of Device Associated Infection in Precisely Tribal Sickle Cell Disease children above 10 years of Age Admitted to ICU of a Tertiary Care Hospital of Tribal Area...... 94 Monalisa Subudhi, P.A.T.Jagatheeswary , Sudhanshu Kumar Das, Arakhita Swain, Rashmi Ranjan Rout
16. A Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding Aerobic Exercise in Treating Dysmennorrhoea among Adolescent Girls, Haldwani, Uttarakhand...... 102 Neha joshi, Babita Bisht, Sonu Khanka
17. Dynamics of Utilization of Modern Contraception by the Females of Slums of Noida...... 109 Nidhi Pundhir, Arindam Das
18. Socio-Economic Determinants of Maternal Health Care Payments among Women in India...... 117 R. Vivekanandhan, A.K. Ravishankar
19. A Comparative Study to Evaluate the Marginal Fit and Fracture Resistance of Peek Material with two Other Restorative Crowns Fabricated Using Cad – Cam Technology – An In Vitro Study...124 Rajevandra Jayesh, P. Praveen
20. Prospective Study of Blunt Trauma Chest...... 132 Ram Gopal Sharma, Piyush Kumar Sinha, Rachith Sridhar. , Nitesh Singh, Duvaraha Devi C Arun Shankar V V, Himanshu Tanwar
21. A study on Modifiable Risk Factors for Healthy Lifestyle in Medical and Nursing Students, HIMS, Sitapur...... 142 Ravi Pachori, Jiratithigan Sillapasuwan, Shakeel A. Qidwai
22. A Study on Prevalence of Cardiovascular Disease Risk Factors Among Medical and Nursing Students, HIMS, Sitapur...... 152 Ravi Pachori, Jiratithigan Sillapasuwan, Anil Kumar
23. Prevalence of MRSA and its Antibiotic Susceptibility Pattern in a Tertiary Care Center,Karimnagar.159 G. Sowjanya, Archana ARK, G Swetha, V.Praveen Kumar III 24. Relationship between Coping Styles and Conversion Disorder Phenomenology: A Study from Eastern India...... 164 Soumen Nandi , Rajarshi Chakravarty, Somsubhra Chattopadhyay, Shuvendu Datta, Kanika Das, Supantha Chatterjee
25. The Diagnostic Information Systems: A Pragmatic Approach ...... 174 Vijay Kumar Tadia
26. Challenges of Rural Healthcare Infrastructure: A Study among North-Eastern States of India...... 181 Manuranjan Gogoi , Sarat Hazarika, Khirod Kr. Phukan, Purabi Gogoi
27. The Effect of Fibrin Glue Application as a Sealant in Protecting Colon Anastomosis with Continues Suture Compared to Simple Interrupted Suture in Intraperitoneal Infection Condition Measured by Tissue Hydroxyproline Level (Wistar Rat Study)...... 191 Agung Fuad Fathurochman, Vicky Sumarki Budipramana, Jusak Nugraha
28. Evaluation of Neurosensory Deficits Following the Use of Computer Assisted Surgical Guide for Inferior Alveolar Nerve Bypass versus Inferior Alveolar Nerve Lateralization (Randomized Controlled Trial)...... 198 Ahmed Ebrahim Abdo , Hesham Abd-Elhakam , Ghada Abd-Elmonim
29. Factors Affecting Adherence to Oral Contraceptives ...... 205
Ahmed Mohammed, Mohammed Abujamal, Mariam Abdalla 30. Approaches Used to Improve Adherence to Oral Contraceptives...... 211
Ahmed Mohammed, Mariam Abdalla, Mohammed Abujamal 31. Detection of Field Cancerization in The Clinically Normal Oral Mucosa of Cannabis and Cigarette Smokers...... 216 Ali Abd El Wahed Kotb, Hatem Wael Amer, Heba Mahmoud Dahmoush
32. Platelet To Lymphocyte Ratio Relationship With Neoadjuvant Chemotherapy Of Caf Regiment Response In Locally Advanced Breast Cancer Patients...... 223 Ali Sibra Mulluzi; Hantoro Ishardyanto; Iskandar Ali; Hartono Kahar
33. Social Aspects of Unwanted Teen Pregnancy Management: a Case Report...... 230 Noviana Ingmiati Tjung, Arnold Kabaria Serworwora, Kevin Yonathan
34. Association of Patient Characteristics with in Vitro Fertilization (IVF) Failure in Graha Amerta Fertility Clinic Dr. Soetomo General Hospital, Surabaya...... 234 Ashon Sa’adi, Wigaviola Socha Purnamaasri Harmadha, Ni Wajan Thirtaningsih, Hamdani Lunardhi
35. Trend of Traffic Accident From 2012 Until 2016 Based on The Accident Report Data and Police Investigation Report in Bogor City ...... 241 Bunga Oktara
36. Type 2 Diabetes, Religious Beliefs and Psychological Interventions...... 246 Charity N. Onyishi, IV 37. Effect of Flexibility Exercise on Symptom Distress of Cancer Patient Undergoing Chemotherapy ....251 Christine Handayani Siburian, Ikhsanuddin A. Harahap, Ridha Dharmajaya
38. A Qualitative Study: The Phenomena of Child Marriage in Urban Areas of Surabaya City Reviewed from Comprehension of Reproductive Health...... 260 Dessy Fitriana, Rize Budi Amalia, Nur Ainy Fardana
39. Assessment of Physical Activity among Female Undergraduate Students of Umm Al-Qura University ...... 266 Faisal A. Barwais
40. Assessment of Lifestyle and Its Relation with Diabetes Mellitus in A Selected Under Privileged Community in Dhaka City, Bangladesh...... 272 Farhana Faruque Zerin, Nasrin Akter, A.K.M Shafiul Kadir, Nishad Shahidullah, Jahidul Bari
41. Topical Anesthesia versus Hand Weight Bearing on Modulating Upper Limb Spasticity in Hemiplegic Children...... 280 * Heba A. Bahey El-Deen, Hala Ibrahim Kassem, Khaled Takey Ahmed , Khaled Ahmed Olama, Radwa S. Abdul-Rahman
42. Effect of Hydro-Aromatherapy on Heart Rate in Heart Failure Patients ...... 287 Huwaina Af’idah , Syafruddin Ilyas , Ikhsanuddin Ahmad Harahap
43. Implementation of Effective Nurse Communication in Hospital Through Electronic Nursing Documentation (END) ...... 294 I Wayan Gede Saraswasta, Rr. Tutik Sri Hariyati, Krisna Yetti , Tuti Nuraini
44. Retrograde Urethrography Examination in Penile Fracture: Case Report...... 300 Iwan Purnomo Aji, Fikri Rizaldi
45. Cyber-Pornography Addiction among Medical Students of Telangana...... 303 K.Hari Praveera, M.Anudeep, Syam Sundar Junapudi
46. Impact of Educational Program for Adolescents and Young Adults with Sickle Cell diseases on their knowledge, Perception, and Self-Care...... 310 KhadigaAbdElgiedGomea Hassan, Shereen Ahmed AhmedQalawa
47. Comparative Health Policy Analysis between Patient and Client Safety Strategy (PCSS) of Finland, 2017 and National Patient Safety Implementation Framework (NPSIF) of India, 2018...... 319 Kirtimayee Soumyadarshinee
48. Immunohistochemical assessment of MMR Proteins, BRAF Mutation and Beta-Catenin in Colorectal Carcinoma in Egypt...... 324 Marwa. A. Ahmed, Mohammed. A. Nouh, Hoda. Ismael, Salim. E. Salem, Ahmed. Rabie, Asmaa. I. Salama
49. Linking between Contamination of Environmental Water and Salmonella Foodborne illness: A Review...... 332 Md. Sayedul Islam, Md. Rashidul Islam, Md. Tuhinur Rahman, Mst. Umme Habiba, Md. Nahian Rahman, Oumma Halima, V 50. Clinical Relevance of Cognitive Behavior Language Therapy in Treating Aphasia among Stroke Patients ...... 341 Mkpoikanke Sunday Otu, Kay C. N. Onyechi, Chiedu Eseadi, Raphael Oluwasina Babalola Folorunsho,
51. In Silico analysis of Phospho Enolpyrovate Carboxylase gene...... 344 Noor Alwash:
52. Hepatitis C Virus Detection In Oral Squamous Cell Carcinoma...... 352 Noura Mohamed Kamal; Heba Mahmoud Dahmoush; Hend Mohammad Waguih Mahmoud Salem Emad S. Helmy
53. The Impact of Covid-19 on Migrant’s Workers Employment and Livelihood in India...... 362 Prithwiraj Swargiary, Priyambee Swargiary, Detsung Swargiary
54. Relationship between Procalcitonin and C-Reactive Protein on Pelod Score in Pediatric Surgery Sepsis Patients at Dr Soetomo General Hospital Surabaya...... 370 Putu Andika Rama Wismawan; Ariandi Setiawan; Jusak Nugraha
55. Comparison of Colonic Anastomosis Using Dry Amnion Membrane and Fibrin Glue in Intraperitoneal Infection Condition Assessed from Tissue Hydroxyproline Level Measurement (Study on Wistar Rat) ...... 379 Rifqi Zulfikar, Vicky Sumarki Budipramana, Hartono Kahar
56. Clinical Application of Rational-Emotive Health Education for Stress Management in Teachers...... 385 Adaobiagu N. Obiagu, Chiedu Eseadi, Okechukwu O. Nwaubani, and Paul N. Onwuasoanya
57. Relationship of Work Irrational Beliefs with Burnout among Nigerian Nurses...... 390 Chiedu Eseadi, Boitumelo Molebogeng Diale,, Vera Victor-Aigbodion, , Raphael Oluwasina Babalola Folorunsho,, Rowland C. Uwakwe, Paul N. Onwuasoanya9
58. Developing Clinical Preceptor Protocol In Clinical Teaching For Nursing Profession Students at General Hospital Dr. Pirngadi Kota Medan, Indonesia ...... 395 Rispalina, Dewi Elizadiani Suza, Nurmaini
59. Changes of Consciousness Level and Blood Pressure of Acute Stroke Patients Administering Mannitol Therapy...... 400 Rofina Sari Jefrianda, Ridha Dharmajaya, Rosina Tarigan
60. The Impact of Work-Family Conflict and Emotional Intelligence on Nurse’s Performance at Dr. Pirngadi Hospital Medan...... 407 Romauli E. G. Siallagan, Arlina Nurbaity Lubis, Sri Eka Wahyuni
61. Impact of Unrealistic Optimism on the Risk of Contamination During The Home Confinement of COVID-19 in Algeria...... 413 Saad Eddine Boutebal , Samia Yahi, Azzeddine Madani
62. Effects of Multimodal Episodic Memory Training in a Community-dwelling Elderly Population with Cognitive Impairment: A Pilot Study on Brain Imaging Outcomes...... 426 Saifon Bunyachatakul, Phuanjai Rattakorn, Peeraya Munkhetvit, Sompong Sriburee VI 63. Validity and Realiability Test of The Indonesian Version for Diabetes Quality of Life - Brief Clinical Inventory ...... 434 Sevia Rani Irianti, Anggi Lukman Wicaksana, Heny Suseani Pangastuti
64. The Effect of Virgin Coconut Oil (VCO) with Lotion on the Skin Moisture among Uremic Patients Undergoing Hemodialysis...... 440 Siti Saodah, Imam Budi Putra, Cholina Trisa S
65. Effect of Global Postural Re-Education and Static Stretching on Pain and Disability in Women with Chronic Non-Specific Neck Pain- A Comparative Study...... 447 Sneha Somarajan 1 , Dr. Dharti Hingarajia 2
66. Comparison on Perception and Attitude of Patients Seeking Private College and Private Clinic In Chennai City – A Cross Sectional Study ...... 454 Suba.A , Lubna Fathima, Sunayana Manipal, Prabu. D, Raj Mohan, Bharathwaj
67. The Usefulness of Computer Assistive Technology for Persons with Visual Impairment...... 459 Sulagodu Prakash Bhavna, Beula Christy, Sania Sulthana, Prasanna Reddy
68. Evaluation of Maternal Health Services at Session Site During Health and Nutrition Day in Urban Slums of Western Odisha...... 466 Sushree Priyadarsini Satapathy, Bharati Panda, Jasmin Nilima Panda, Sadhu Charan Panda
69. Food Insecurity and Its Association with Nutritional Status among Women of Reproductive Age Group in Noakhali District, Bangladesh...... 475 Syeda Saima Alam, Md. Rhead Hossain, Md Abdullah Al Mamun, Md. Nahian Rahman, Tanzina Akhter
70. Nutritional Status of Under-five Children among Urban Slum Dwellers in Dhaka City, Bangladesh. .484 Tanjina Rahman*, Md. Abdullah Al Mamun, Susmita Ghosh, Shakil Ahmed, M. Akhtaruzzaman, Fahmida Karim Munni, Sumaiya Chowdhury
71. The Effect of Dried Amnion Membrane Application in the Expression of Platelet Derived Growth Factors in the Healing Process of Stomach Stab Wound (Study on New Zealand Rabbit)...... 495 Yipno Wanhar, Fendy Matulatan, IGB Adria Hariastawa
72. Analysis of the Risk Factors for Sexual Dysfunction in Stoma Patients ...... 501 Zuliawati, Siti Saidah Nasution, dan Asrizal
73. Biochemical Evidence of Overweight, Androgen Excess and Hyperinsulinaemia in Women with Polycystic Ovarian Syndrome in Nauth, Nnewi, Nigeria...... 510 Nkiruka R Ukibe, Charles T Chigbo, Charles C Onyenekwe, Adaobi A Chigbo, Anya O Kalu, Ejatuluchukwu Obi, Ezinne G Ukibe
74. Prevalence and Pattern of Musculoskeletal Problem among Software Engineers in a Private Firm, Chennai- A Cross Sectional Study...... 517 Jasmine M , Ravivarman G , Vinoth Gnana Chellaiyan, Buvnesh Kumar VII 75. The Prevention Program of Cervical Cancer in Public Health Settings: A Review...... 524 Anggi Lukman Wicaksana,, Nuzul Sri Hertanti
76. Developing Mobile Application for Predicting Risk of Cardiovascular Event among People with Diabetes: Design and Pilot Study...... 530 Anggi Lukman Wicaksana,,, Andri Cipta, Nadhifah Azzahrah Yumna, Muhammad Nabhan Naufal
77. A Review of Harmful Aspects of Mobile on Health and Environment...... 538 Monika Dubey
78. Polycyclic Aromatic Hydrocarbons in Fresh and Smoked Clupea heregus and Hake Fish Consumed in Ekiti State, Nigeria and their Health Implications...... 545 Adeolu J. Adesina, Samuel S. Asaolu, Samuel O. Adefemi, Abdul A. Olaleye, Abiodun F. Akinsola, Kolade A. Idowu DOI Number: 10.37506/ijphrd.v12i1.13819 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 1 Utilization of Health Care Services among the Farmers of Rural Field Practice Area of Department of Community Medicine KIMS, Hubballi: A Cross Sectional Study
Anjana R Joshi1 , Dattatraya D Bant2 1Post graduate, 2Professor and Head, Department of Community Medicine, Karnataka Institute of Medical Sciences, Hubballi.
Abstract Background: Farmers suffer from a multitude of problems; from the socio-economic problems to that related to their health. Availability of quality services at the nearest possible areas at the reasonable or no cost results in better utilization of health services.
Objectives: To assess the illness behavior among the farmers and to assess the utilization of health care services and to assess the barriers for utilization of health services
Methodology: A community based cross sectional study was conducted in the rural field practice area of KIMS, Hubballi among 324 farmers. House to house survey was conducted using pre designed semi- structured piloted questionnaire.
Results: Out of 324 farmers, majority were males, Majority of the study participants were small scale farmers. Government hospital was the first priority for 39.5% of the farmers. Majority of the farmers did not complete the course of treatment.. The choice of health care facility was associated with the gender and the distance from the health care facility. Distance (32.4%) to the health care facility was reported as the main barrier for utilization of public health services.
Conclusion: The health care preference for public and private is equal among the study participant. There is a significant gender difference in the preference of health care facility. The barriers for the utilization should be addressed to enhance the proper utilization of public health care services.
Keywords: Farmer, Utilization of health service, Government facility, illness behavior
Introduction availability of quality services at the nearest possible areas at the reasonable or no cost results in better India is a land of agriculture. Agriculture plays a utilization of health services.3 vital role in India’s economy. It contributed to 14.5 %of India’s GDP (2017-18).1 Farmers are the bread makers Various health care facilities are available in the of the world. rural areas since ancient times in India: Traditional healers/ faith healers, AYUSH, self medication, modern Farmers suffer from a numerous problems; socio- medicine economic-environmental problems and also the health problems.2 Majority of the farmers neglect their health Public health care delivery in rural India includes resulting in delay in seeking care and poor utilization of Subcentres equipped with ANMs, Primary health health care services. centers, Community Health Centers.3,4
Availability of Health care services at the rural areas As majority of the farmers neglect their health and plays an important role in their health-seeking behavior, disease amidst the farming activities and the ignorance 2 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
about the severity of illness and its consequences, this socio-demographic details, utilization of the health care study gives the idea about the illness behavior and services during the illness and barriers for the utilization utilization of health services among the farmers. of government of health services.
Objectives: Informed written consent was taken from the study participants. The study was approved by Institutional 1. To assess the illness behavior among the ethical committee. farmers. As majority of the private practitioners in rural 2. To assess the utilization of health care services areas will be AYUSH practitioners. AYUSH and Private and to assess the barriers for utilization of health services Practitioners were grouped and were used for analysis.
Methodology Data Analysis: The data was entered in MS Excel A Community based cross sectional study was and analyzed using SPSS v21, Suitable descriptive and conducted in the field practice area of department of inferential statistics were used for the study. Monte community medicine among the farmers aged between Carlo exact test of significance was used. 18-60 years residing in the Kalghatagi Taluk, Dharwad district Results Socio-demographic characteristics: Out 324 Duration of the study: One year (June 2018 to farmers, 69.8% of them were males and 30.2% were May 2019)] females. Majority (39.8%) of the farmers were in the Marginal and Small scale farmers aged between 18 age group of 50-60years, followed by 30-40 years(25%), to 60 years were included in the study. Farmers with 40-50 years and 18-30 years. 54.9% of the farmers serious illness and pregnant and lactating farmers were were literates, 45.1% were illiterates. Majority of the excluded. farmers (53.4%) stayed in nuclear families followed by three generation family and joint family. Most of Cluster sampling was used for the selection of them belonged to class IV socio-economic status (67%), villages of Kalghatagi taluk comprising of 6 PHCs 16.7% and 16.4% belonged to Class III and Class V according to modified BG Prasad classification. Out Cluster A: villages which are within the range of 5 of 324 farmers 51.2% of the farmers were small scale km from the corresponding PHC farmers, followed by marginal farmers (38.9%) and Cluster B: villages which are more than 5 km away agricultural laborer (9.9%) from the corresponding PHC Characteristics of illness behavior: Majority of the One village from each cluster was selected randomly farmers attempted to treat the illness in the previous six from all the 6 PHCs of Kalghatgi taluk. Totally 12 months. majority of the farmers (39.6%) of the farmers villages were selected for the study. visited the health care facility the next after the onset of illness( Table 1) Equal number of farmers was selected from each village by systematic random sampling. Preferences of health facility: The preference for private and government hospital was almost equal Sample size: The sample size was calculated using and the many farmers also preferred pharmacies as well 2 2 the formula n= 1.96 pq/l based on the previous study (Table 2) among the farmers in Titabor block in Assam5, in which 62 % of the farmers visited government hospital during The choice of health care facility was associated with their illness, the sample size of 324 was used for the the gender and the distance from the health care facility. study Majority of the female farmers preferred government health facility where as males preferred private (Table 3) Study tool: Predesigned semi structured piloted questionnaire was used for the study consisting of Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 3
Barriers for health care utilization: distance (32.4%) to the health care facility was the main barrier for utilization, 30.2% of the farmers reported insufficient staff, drugs and other services was the barrier. (Table 4)
Table 1: Illness behavior among the farmers
Frequency(N) Percent (%)
Yes 308 95.1 Attempt to treat illness(N:324) No 16 4.9
Same day 52 16.9
Next day 122 39.6
Duration between the onset of symptoms and health care seeking(N: 2 days later 77 25 308)
3-7 days 41 13.3
More than 7 days 16 5.2
Early stages of disease and onset of 133 43.2 symptoms mild Stage of the disease at the time visit to health facility Incidence of disease and its symptoms 110 35.7 (N: 308) In serious stages of disease 65 21.1
Government Hospital 59 19.2
Private hospital 174 56.5
Mode of treatment at the first step Pharmacy 43 14 (N: 308)
Traditional healer 14 4.5
Self medication 18 5.8
Till recovery 55 17.9
Course of treatment To relieve the symptoms 145 47.1 (N: 308)
Not completed the course 108 35.1 4 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 2: Preferences of Health care facility during illness
1st choice of treatment 2nd choice of treatment
Frequency (N) Percent(%) Frequency(N) Percent(%)
Self Medication/Home remedies 18 5.6 6 1.8
Traditional Healer 5 1.5 4 1.23
Pharmacies 40 12.3 19 5.86
ANM/Anganwadi 7 2.2 5 1.54
Government hospital 128 39.5 150 46.3
Private / AYUSH 126 38.9 140 43.2
Total 324 100 324 100
Table 3: Association between the socio-demographic factors and the preference of health care facility
Priority of health care Self medication/ Traditional ANM/ Government Private Pharmacies Total P value facility home remedies healer Anganwadi hospital practitioner
<5 km 9(5.6%) 1(0.6%) 13(8.0%) 0 68(42%) 71(43.8%) 162(100%) Distance Chi square: 16.231 from nearest Degrees of freedom: 5, primary health centre P value: 0 .006* >5km 9(5.6%) 4(2.5%) 27(16.7%) 7(4.3%) 60(37%) 55(34%) 162(100%)
Male 12(5.3%) 1(0.4%) 27(11.9%) 5(2.2%) 79(35%) 102(45.1%) 226(100%) Chi square: 17.460, Gender Degrees of freedom: 5, P Female 6(6.1%) 4(4.1%) 13(13.3%) 2(2%) 49(50%) 24(24.5%) 98(100%) value: 0.004*
Illiterate 9 (6.2%) 3(2.1%) 19(13%) 4(2.7%) 57(39%) 54(37%) 146(100%) Chi square: 1.399, Literacy Status Degrees of freedom: 5, P Literate 9(5.1%) 2(1.1%) 21(11.8%) 3(1.7%) 71(39.9%) 72(40.4%) 178(100%) value: 0.928
Class III 2(3.7%) 1(1.9%) 6(11.1%) 1(1.9%) 19(35.2%) 25(46.3%) 54(100.0%)
Chi square: 5.538, degrees of freedom: 10, SES class Class IV 15(6.9%) 4(1.8%) 28(12.9%) 5(2.3%) 84(38.7%) 81(37.3%) 217(100%) p value: 0.867,
Class V 1(1.9%) 0 6(11.3%) 1(1.9%) 25(47.2%) 20(37.7%) 53(100%)
P value: <0.05, Significant Monte-Carlo exact test was used Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 5
Table 4: Barriers for utilization of health services at government health facility
Barriers Frequency(N) Percentage (%)
Distance To The Health Facility 105 32.4
Cost 14 4.3
Insufficient Staff/Drugs And Other Services 98 30.2
Poor Health Workers Attitudes 50 15.4
Cultural Beliefs 9 2.8
Poor Services Offered at the health facility 48 14.8
Discussion preferred mainly private hospital may be because of the time constraint for males to lose their wages. In the present study 324 marginal and small scale farmers were included in the study in which 69.8% of In the study by Syeda S J5 majority of the farmers the farmers were males and 30.2% of the farmers were preferred government hospital,17% of the farmers females. preferred private practitioners, 11% of the farmers sought care from traditional healers and 10% from Pharmacies. In a study by Rajesh R Kulkarni2, among farmers in Similar study conducted by Rajesh R K2, 48.75% of Belgaum district, 55.75 % of the farmers were males and the farmers preferred government hospital, 28% of 44.25% of the farmers were females. In a similar study the farmers preferred private/ AYUSH practitioners, by Saket Anil Patil32 among farmers in Maharashtra 12.25% of the farmers preferred Anganwadi worker and majority of the study participants were males (61.82%). only 1% of the farmers preferred Pharmacist. The treatment choice of any person depends on In a study conducted by Sangamitra85 in Theni many factors that may be related to illness type, severity, District among agricultural workers, most of the familial factors and cultural beliefs, age, gender, options agricultural workers (70%) sought care in private of health facility available, distance from the health care hospitals and 30 per cent of workers sought care in facility, services offered by the health facility, cost of Government hospital. They reported the main reason care, previous experience with the health facility, trust for preferring private hospital was the time constraint, and reliability of the health professionals. they do not want to lose their wages to visit government In the present study preferences of healthcare facility health care facility, they reported that the quality of were assessed, Government hospital was the first priority services offered in government facilities was poor for 39.5% of the farmers.38.9% of the farmers preferred In the present study 32.4% of the farmers reported private practitioners/ AYUSH practitioners. 12.3% of that distance to the PHC( health facility ) was the main the farmers preferred Pharmacies. Self medication was barrier for seeking care at government hospital(PHC), practiced by 5.6% of the farmers. Traditional healers Insufficient staff/ drugs and other services was reported were preferred by 1.5% of the farmers. by 30.2% of the farmers. In the present study the preference of health care facility was associated with the gender and distance Conclusion of health care facility. Female farmers preferred The present study concluded that the utilization of government facility was high among females and males public health services and private services was almost 6 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 equal with the utilization of Public health services less Health 2013; 3(1):33-7. than the 50% which shows the need of improvement of 3. The Health Belief Model - Rural Health Promotion public health services and there is a need to address the and Disease Prevention Toolkit [Internet]. barriers for utilization. Ruralhealthinfo.org. 2019 [cited 7 September 2019]. Available from: https://www.ruralhealthinfo.org/ Ethical Clearance: Taken from Institutional Ethics toolkits/health-promotion/2/theories-and-models/ Committee, Karnataka Institute of Medical Sciences, health-belief Hubballi. 4. A World Health Organization resource: the role of Source of Funding: Self pharmacist in self- care and self-medication(1998; 17 pages) pdf. Conflicts of Interest: Nil 5. Rahman S, Das B, Nath G. Health seeking behavior of farming community in rural area of Titabor References block in Jorhat district. International Journal Of 1. Data.worldbank.org. (2019). Agriculture, forestry, Community Medicine And Public Health. 2017; and fishing, value added (% of GDP) | Data. [online] 4(10):3854. Available at: https://data.worldbank.org/indicator/ 6. Sangamitra A. A Study on Health-Seeking NV.AGR.TOTL.ZS [Accessed 26 Jun. 2019]. behaviour among Agriculture Workers in Theni 2. Kulkarni RR, Shivaswamy MS, Mallapur MD. District. Shanlax International Journal of Arts, Health-seeking behavior of rural agricultural Science & Humanities. 2016; 4(1):21-25. workers: A community-based cross-sectional study. International Journal of Medical and Public DOI Number: 10.37506/ijphrd.v12i1.13820 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 7 The Role of Serum LDH Level an Early Marker and Prognostic Indicator for Megaloblastic Anemia in Children
Ankit Gupta1, Ravanagomagan2, R.S.Sethi3 1Consultant Paediatrician District Woman Hospital, Orai, Uttar Pradesh, 2Assistant Professor Sree Balaji Medical College and Hospital Chennai,3Professor, Department of Paediatrics, Maharani Laxmi bai Medical College, Jhansi
Abstract This prospective study was conducted among 30 children who had clinically suspected megaloblastic anaemia in a tertiary care hospital. With a purpose to study the role of serum Lactate dehydrogenase (LDH) level as an early marker and prognostic indicator for megaloblastic anaemia in children. After Children’s were identified by taking detailed clinical history and examination were subjected for the various investigation, then LDH level were co-related with the duration of illness, severity of anaemia, and clinical response to treatment. Statistical data was analysed using graph-pad. The commonest age group was between 5-10yrs (n=17, 56.6%), showing male: female ratio (M:F, 1.5:1), 84%were from low socio-economic background. Those children who had longer duration of illness had higher serum LDH level. Serum LDH levels falls in responsive to the therapy. The study concludes that megaloblastic anaemia is still a common and preventable cause of anaemia in school going children and adolescents. Early recognition of megaloblastic anaemia with simple investigation like serum LDH level estimation and subsequent effective therapy will have a good outcome.
Keywords - Megaloblastic Anemia, Lactate dehydrogenase(LDH), Vitamin B12,prognosis and outcome
Introduction Megaloblastic anemia is a common preventable disease in young children, higher rates occur in Anemia is a major global health problem, especially developing countries, with predominantly in lower in developing countries [1]. Megaloblastic anemia socio-economic background and also in vegetarians. encompasses a heterogeneous group of anemias characterized by the presence in the bone marrow of Nutritional megaloblastic anemia in children occurs large red blood cell precursors called megaloblasts[2]. commonly among under-nourished or malnourished societies of tropical and subtropical countries. The Osler and Gardner in 1877 noted the association commonest age is 3-18 months with maximum number with neuropathy, and 10 years later Lichtheim of cases being in 9-12 months[4]. These children are documented myelopathy. Megaloblasts were identified generally exclusively breast-fed by mothers who are for the first time by Ehrlich in 1880. In 1920, abnormalities undernourished and have poor blood levels of folate and in white blood cells were described. In 1926, Minot and cobalamin[5,6,7]. Murphy showed that the disease could be reversed by the intake of large quantities of liver [3]. This condition is due to impaired DNA synthesis, which inhibits nuclear division. Cytoplasmic maturation, Corresponding author: mainly dependent on RNA and protein synthesis, is less Ravanagomagan impaired; this leads to an asynchronous maturation 42/4W, palani andavar kovil Street, Kottur - Post, between the nucleus and cytoplasm of erythroblasts, Veerabandi-Via, Theni-District & Taluk - explaining the large size of the megaloblasts[8]. 625534 (Tamilnadu) Phone No.: +91 9865965921 E-mail: [email protected] 8 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Lactate dehydrogenase (LDH) is a true intracellular done were excluded from the study. enzyme found in many body tissues particularly heart, Our study was approved by ethical committee of liver, skeletal muscles, kidney and red blood cells[2]. our medical college and hospital. All those children with LDH has five isoenzymes. related haematological finding and low serum vitamin Gross elevation of serum LDH in megaloblastic B12 were subjected for serum LDH level estimation on anemia was first reported in 1955 by Hess [9]B . day 1 day 4, day 14 of therapy.
Serum LDH estimation can be used as a screening Serum vitamin B12 was measured by test for the diagnosis of megaloblastic anemia before chemiluminescence assay(using automated bioanalyzer performing a bone marrow aspiration[10]. Winston R et al, by Siemens) and serum LDH was measured by LDH kit, Jaswal T et al had shown a characteristics reversed LDH which is specifically detected by colorimetric assay.LDH isoenzyme pattern i.e. LDH1>LDH2 in megaloblastic level were correlated with duration of illness, severity of anemia[11,12]. anaemia and clinical response to treatment.
LDH levels peak at 3-4 days and remain elevated Results for 10 days. It is considered that LDH originate in the This hospital based study comprised of total 30 megaloblast of the bone marrow. The decision as to children’s with evidence of megaloblastic anemia which whether megaloblastic anemia is due to folic acid or formed the study group. vitamin B12 deficiency is sometimes difficult. In such instance it may be necessary to carry out a therapeutic Out of 30 children which formed the study group, trial with physiological amount of folic acid and to commonest age group was between 5yrs to 10yrs (n=17, assess response by daily means of reticulocyte counts. 56.6%). Male 18 and female 12 ratio was (M:F :: 1:5), Serial LDH level estimation is seen to be at least as 84% were from low socio-economic background. valuable as reticulocyte count in assessing the response Predominant clinical presentation were pallor(100%) [13] of treatment .Levels of total serum LDH will also help malaise and lethargy(70%), glossitis and cheilitis(18.1%) in differentiating megaloblastic anemia from hemoglytic while neurological manifestation occurred only in 2% [14] anemia .There was rapid fall in LDH activity during of cases. In the study group, 75 %( n=24) of the case of treatment with vitamin B12 corresponding to increase in megaloblastic anemia was due to combined deficiency [15] reticulocyte count .Early recognition of megaloblastic of vitamin B12 and folic acid, whereas 25%(n=6) of the anemia with simple investigation like serum LDH level cases were due to vitamin B12 deficiency. can also help in assessing the prognosis of megaloblastic anemia in children. In these children following LDH correlation were noted. Children who had longer duration of illness From the above evidences we have taken our study had higher LDH levels, those children who had lower about LDH in Megaloblastic anemia. haemoglobin at admission had higher LDH levels, those with haemoglobin (Hb)<4 gm/dL(n=10,33.3%) had Method mean LDH levels of 1337IU/L; those with haemoglobin This is a prospective study. Conducted in a tertiary 4-6 gm/dL(n=15,50%) had mean LDH levels of 1120 care hospital, north India from September 2014 to IU/L; those with haemoglobin >6 gm/dL had mean LDH October 2015. A total number of 30 children from level of 537 IU/L. The children who had higher MCV Paediatric unit in M.L.B. Medical College, Jhansi had higher LDH levels, children with MCV 90-110 fL/ formed the study group. Those children who fulfilled l(n=5,16.6%) had mean LDH levels of 1282IU/L, those the following criteria were selected as the study group who had MCV 100-110fL/l (n=17,70%) had mean LDH : children with age group ranges from 2year-18 years, levels of 1343IU/L and those whose MCV >110fL/ children with low serum vitamin B12 levels, vegetarian L(n=4,13.3%)had mean LDH level of 1374IU/L. baby and children whose MCV>90fL/L. Children with Children who had higher vitamin B12 levels had higher iron deficiency and whose vitamin B12 levels were not LDH level, children with vitamin B12 level of<100 pg/ Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 9 ml(n=8,26.6%) had mean LDH level of 1303IU/L, those The difference between mean haemoglobin at day who had vitamin B12 level of 100-150 pg/ml(n=15,50%) 1 and day 14 of illness was found to be statistically mean LDH level of 1090,those who had vitamin B12 signifi cant (p=0.0001). The difference between mean level of 150-200 pg/ml(n=7,23.4) had mean LDH level MCV at day 1 and day 14 of illness was found to of 925. statistically signifi cant (p=0.0001) and the difference between mean LDH with duration of illness was found to be statistically signifi cant (p=0.0001).
Illustrations: Male vs female
Distribution by age group 10 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Percentage of symptomatology in study group
Distribution of cases according to the cause of megaloblastic anemia Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 11
Discussion major limitation of this study.
The present study entitled “THE ROLE OF Thus to conclude serum LDH as a marker of SERUM LDH LEVEL AN EARLY MARKER prognostic indicator-as fall in serum LDH levels was AND PROGNOSTIC INDICATOR FOR seen in all children, in response to treatment with MEGALOBLASTIC ANEMIA IN CHILDREN” vitaminB12.Serum LDH levels returned to normal in all was carried out in department of paediatrics, Maharani children on day 14 of therapy. Megaloblastic anaemia is Laxmi Bai Medical College, Jhansi, Uttar Pradesh still a common preventable cause of anaemia in children especially in school going children and adolescent. The study group consisted of 30 children’s ranging Early recognition of megaloblastic anaemia with simple from 2 year to 18 years. investigation like serum LDH levels and effective Out of total 30 cases, 18(60%) were male and therapy will have a good outcome. 12(40%) female. The male: female ratio was 1.5:1. Conclusion Out of these, majority number of cases belongs to Megaloblastic anaemia is still a common preventable age group of 5-10 year about 56.6%. cause of anaemia in children of india especially in school Majority of cases had symptomatology of pallor going children and adolescent. LDH is a non invasive (anemia) while few cases had hepato-splenomegaly, and simple and cost effective procedure does not require while few were CNS related(2%). an expert. With LDH early recognition of megaloblastic anaemia can be done easily. The present study shows megaloblastic anemia is mainly due both vitamin B12 and folic acid deficiency Ethical Clearance: Obtained from ethical (n=24, 75%). The study depict that children who had committee Maharani Laxmi Bai Medical College Jhansi, lower haemoglobin and vitamin B12 level had higher Uttar Pradesh LDH level and children who had higher MCV had higher Source of Funding: Self LDH level. The study also depicts, the role of LDH with mean duration of illness, those children who had Conflict of Interest: Nil longer duration of illness had higher serum LDH levels, children with duration >4 weeks (n=8, 26.7%) had mean References LDH value of 1100IU/L duration between 2-4 weeks 1. Milman N. Anemia-still a major health problem (n=15, 50%) had mean LDH of value and duration <4 in many parts of the world. Ann Hematol. weeks (n=7, 23.3%) had mean value of 540IU/L. 2011;90(4):369-77
When comparing LDH with the parameter like 2. Wickramasinghe SN. Diagnosis of megaloblastic anaemias. Blood Rev. 2006 Nov;20(6):299-318 haemoglobin, Vitamin B12 level, their level increases after response to therapy with Vitamin B12 from day 3. G.R. Minot, W.P. Murphy Treatment of pernicious 1 to day 4 mean haemoglobin value was 4.4 +1.52on anemia by a special diet Blood, 3 (1948), pp. 8-21 day 1 and on day 14 haemoglobin level were 9.5 +1.02. 4. Mittal VS, Aggarwal KN. Observations on Comparing serum LDH on day 1 and day 14 of illness, nutritional megaloblastic anaemia in early their value formed to be decreases with response to childhood. Indian J Med Res 1969; 57: 730-738 treatment, with mean value of LDH was 123.9 +36.0 on 5. Baker SJ, Jacob E, Rajan KT, Swaminathan SP. day 1 and on day 14 was 204.7+24.7. Vitamin B12 deficiency in pregnancy and the puerperium. BMJ 1962; 1: 1658. This study assessed the prognostic value of LDH 6. Bijur Am, Desai AG. Composition of breast milk in megaloblastic anaemia. Our patients had typical with reference to vitamin B12 and folic acid in peripheral smear and other haematological findings with Indian mothers. Indian J Pediatr 1985; 52: 147-150. positive response to therapy .We tested vitamin B12 and 7. Jadhav M, Webb JKG, Vaishnava S, Baker SJ. LDH level in only a less no of patient, and this was a Vitamin B12 deficiency in Indian infants: A clinical 12 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
syndrome, Lancet 1962; 2: 903-907. 13. C.F MC Carthy and I.Dfraser and A.E Read in 8. Green R, Datta Mitra A. Megaloblastic Anemias: journal of clinical pathology, 1966 Nutritional and Other Causes. Med. Clin. North 14. Vinaya Kumar, Mirji G. Evaluation of serum Am. 2017 Mar;101(2):297-31 LDH levels in the diagnosis and inmonitoring 9. Hess B, Gehm E. Lactic acid dehydrogenase in the the response to the treatment in children with human blood. Klin Wochenschr. 1955;33(3-4):91- megaloblastic anaemia. Int J Pediatr Res. 2019;6 3 (05):217-220.doi:10.17511/ijpr.2019.i05.04 10. Eivazi ZJ, Dastgiri S, Sanaat Z. Estimation of the 15. The Activity of Lactic Dehydrogenase in diagnostic value of myeloperoxidase index and Megaloblastic Anaemia-Norman Anderssen lactate dehydrogenase in megaloblastic anemia. J M.D,- https://doi.org/10.1111/j.1600-0609.1964. Clin Diag Res. 2007;1(5):380-384 tb00017.x 11. Winston RM, Warburton FG, Stott A. Enzymatic 16. Levels of serum LDH in diagnosis of diagnosis of megaloblastic anemia. Br J Haematol. megaloblasticanemia: JaswalTS,MehtaHC, 1970;19(5):587-92 GuptaH, SinghM, SinghS :Indian JPathol Microbiol2000 ;43 JUL 12. Jaswal TS, Mehta HC, Gupta V, Singh M, Singh S. Serum lactate dehydrogenase in diagnosis of 17. Estimation of the diagnostic value of megaloblastic anemia. Indian J Pathol Microbiol. Myeloperoxidase Index and Lactate dehydrogenase 2000;43(3):325-9 in Megaloblasticanemia,Journal of clinical and diagnostic research DOI Number: 10.37506/ijphrd.v12i1.13821 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 13 Cog-y Balance Test: Validity and Reliability for Fall Prediction in Community Dwelling Elders
Ankita Gosai1, Dhruvkumar Dave2 1Master of Physiotherapy Student (Fourth Semester), 2Associate Professor, Department of Community Physiotherapy, Ashok and Rita Patel Institute of Physiotherapy, Charusat University, Gujarat, India
Abstract Background: Years lived with disability (YLDs) by the end result of falls were 631 per 1 lakh population in India in 2010 and it is raising till date. The avoidance of fall among older is perhaps one of the prime public health question.
Objective: Aim of our study is to assess the concurrent validity, inter-rater and intra-rater reliability of Cognitive-Y Balance Test (Cog-YBT).
Methods: In this cross sectional study, 29 male and 27 female participants (64.77± 4.66 years) were recruited from the community area. Data collection for the Berg Balance scale (BBS), Cognitive Time Up and Go (Cog-TUG) and Cog-YBT were done for all. Cog-YBT data were taken by two different Data collector (Rater 1 and 2). Rater 1 have taken data for 2 time with adequate rest between two sessions.
Results: Statistically significant (p < 0.05), though weak to moderate correlations were found for Cog-YBT to BBS and Cog-YBT to Cog-TUG comparison (spearman’s correlation coefficient = 0.35 to.0404). ICC score for intra-rater and inter-rater reliability was excellent for Cog-YBT (ICC >0.9).
Conclusion: Though the reliability of cognitive Y Balance test is high in our context, the concurrent validity of this test is not adequate to use it as fall predictor measure in community dwelling elder yet.
Key words: Balance assessment, Aging, fall prevention, Cognitive- YBT.
1, 2 Introduction income developed nations . The prevalence and burden of fall Falls and balance control
More than 70 % of older population of the world The event in which, an individual incidentally comes are habitat in developing countries. Due to increasing to inferior level or directly on the ground is described longevity, this quantity will raise in next decades all as fall. The World Health Organization has stated the over the world1. The major outcome of this change fall as a one of the external causes of accidental injury. is immense share of morbidity and mortality burden The balance is fundamentally concerned with obtaining, because of falls in low and middle income countries correcting or sustaining the centre of mass in connection (LMICs).1 Differences are so far apparent. For instance, with the base of support. The balanced postural is the falls reported years lived with disability (YLDs) were result of integrative function of multiple body systems around 631 per 1, 00,000 population in India, in 2010. In such as motor system, vision and somatosensory inputs that same year, the global percentage of YLDs because as shown in Figure 13. of falls in people aged between 50 to 59 years was 66 % in economically developing nations and 34 % in high 14 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Figure 1. Interactive function of the various body system to control balance.
In older people, the most prevalent cause of trauma Methods is fall which leads to disability, fractures, distress, pain, It was Cross sectional study for reliability and loss of confidence and dependency4. Several walking validity. The study was approved by institutional ethical and balance measures have been proposed previously to committee (year 2017-2019) and data collection were evaluate the risk of falls, but their predictive validity in done from December 2019 to March 2020. Participants active older community people is still controversial5, 6, 7 . were recruited form the physiotherapy OPD and Fall and Dual Task (DT) community area of Anand and kheda district of Gujarat by convenient sampling. One dominant aspect of DT experimentation is the falls risk evaluation, with poor walking capacity in Participants with age between 60- 80 years, who DT conditions predict falls among older adults living were able to walk without assistive devices and without in a various community settings8. Dual tasking is one being supported by another person, able to understand type of complex task. The declination in this type of simple instructions and willing to cooperate with the complex functioning has been associated with fall. As a study process were included in study. The participants whole, slowing down or worsening of performance with with self-reported neurological, cardiopulmonary DT environment can predict falls in elders8. Previous disease conditions, peripheral neuropathy/ altered reviews 9, 10 done to evaluate the prognostic validity of sensation in lower extremity, MMT Grade of < 3 in both DT measures for falls have stated contradictory results lower limbs, Limb length discrepancy > 2cm and any 8, 9, 10. Furthermore, DT tests sounds superior in the fall major surgeries within the past 3 months were excluded prediction in frailer old people8, 9. from study. Total 56 elder participants with mean age 64.77 ±4.66 years, was included for study. Demographic The first objective of our study was to estimate details were taken with the weight, height, limb length, the concurrent validity and reliability of the Cognitive etc. All the data were collected by the trained master Y-balance test (Cog-YBT) in adults aged >60 years by of physiotherapy students. The Flow chart of data correlating it with other standard tools of balance and collection procedure is given in figure 2. During the trial function. and test session, the participant was closely monitored Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 15
by one therapist to avoid any injury or fall and the data collector can solely focus on standard protocol.
Figure 2. Flow diagram of data collection procedure count backward from a randomly selected number from 10 to 100 and then reach out as far as possible with their COG-YBT Procedure right foot and back to the starting position. Presented Testing was performed in a consistent and in figure 3. The Reach distance of each direction was safe environment with a non-slippery surface. Pre- recorded thrice. The composite score was calculated by requirements are, a consistent and reliable testing area the maximum reach distance achieved in 3 direction and (minimum 2 metre2), test administrator (rater 1 and rater the limb length of the participant. 2), Y Balance test tool, Performance recording sheet and NOTE: Attempt was recorded as fail if the 1 supervisor to prevent fall. participants touch their foot down on the floor before Participants were requested to stand bare footed on returning to the starting position or any imbalance or centre area with light clothing. The test was performed stoppage of counting. In addition, the participant must in following sequence with the right leg first followed not put his/her foot on top of the distance indicator in by the left leg, 1. Anterior, 2. Posteromedial, 3. Postero- order to grab support during the reach out – participant lateral reach with their hands firmly placed on their must slide the reach indicator by non-weight bearing leg. waists, participant was instructed to simultaneously 16 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Figure 3. Cog-YBT procedure.
Data Analysis intraclass and inter-class correlation coefficient (ICC 3, 1 and ICC 2, 1) and Cronbach’s alpha. Cronbach’s Statistical analyses for all tests were done using IBM alpha is used to evaluate internal consistency. Internal SPSS 20. Means and standard deviations were calculated consistency is considered acceptable when Cronbach’s for age, body mass, Limb length and height to determine alpha exceeds 0.70. Concurrent Validity was evaluated the participants’ characteristics. The significance level by using spearman’s correlation coefficient (r). was set at p<0.05. For reliability evaluation, 2 different Relationships between the COG-YBT score to BBS tester have collected the data. Intra-rater and inter-rater score and Cog-YBT score to COG-TUG were compared. reliability of Cog-YBT was evaluated by using the Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 17
Results ±8.91 and 60.70 ±8.72 respectively. The mean BBS score was 53.75 ± 1.65 (Range: 49-56) and the mean Total 56 subjects (29 males, 27 females; 64.77 ± 4.66 Cognitive- TUG score was 10.99 ±1.99 seconds (range: years) had participated in this study. The participants’ 7-15). mean body mass and height were 66.63 ± 12.23 kilograms and 160.91 ±9.24 centimetres, respectively. For analysis of concurrent validity, Cog-YBT was The participants’ mean Body Mass Index was 25.70 ± compared to BBS and Cog-TUG. Statistically significant 4.02 kilogram/meter2. correlations (p < 0.05) were found between the Cog-YBT and both of the comparison measures. The spearman’s The participants mean of the composite score of correlation coefficient between Cog- YBT to BBS score cognitive- YBT for the right and left leg were 59.46 and Cog-YBT to Cog-TUG are shown in table 1 and table 2 respectively.
Table 1. Correlation of the cog-YBT score ( both leg) to BBS
Right Leg Left Leg
Mean 59.46 60.70
SD ±8.91 ±8.72
Spearman’s correlation coefficient 0.369 (weak positive) 0.435 ( moderate positive)
Level of significance 0.01 0.01
P value 0.005 0.001
Table 2. Correlation of Cog-YBT of both leg to Cog-TUG
Right Leg Left Leg
Mean 59.46 60.70
SD ±8.91 ±8.72
Spearman’s correlation coefficient -0.313 (weak negative) -0.301 (weak negative)
Confidence interval 95% 95%
P value 0.019 (<0.05) 0.024 (<0.05)
Intra-rater reliability was analysed by comparing the Cog-YBT score of initial test (T1) to the retest (T2) (by Rater 1). The ICC [3, 1] and cronbach’s alpha values of Intra-rater reliability are presented below in table 3. 18 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3. Intra-rater reliability of Right and Left Cog-YBT score at T1and T2
Right Leg Left Leg
Intra class correlation (ICC) (model3) 0.946 (excellent) 0.959 (excellent)
Cronbach’s coefficient alpha 0.972 (excellent) 0.979 (excellent)
Confidence interval 95% 95%
The inter-rater reliability was analysed by comparing the Cog-YBT score of Rater 1 to Rater 2. The ICC [2, 1] and cronbach’s alpha values of Inter-rater reliability are presented below in table 4.
Table 4. Inter-rater reliability of Right and Left leg Cog-YBT score
Right Leg Left leg
Inter class correlation (ICC) (model2) 0.908 (excellent) 0.944 (excellent)
Cronbach’s coefficient alpha 0.952 (excellent) 0.971 (excellent)
Confidence interval 95 % 95 %
Discussion women, both with and without a history of falls 25. Furthermore, Newton RA suggested that BBS need This study is done to investigate the validity and modifications when it is utilised for active older adults. reliability of Cog-YBT in the community dwelling This indicates that the BBS cannot predict a risk of older adults. The results of this study provide evidence falling at higher score 26. Maximum participants of that the Cog-YBT has statistically significant, though this study scored close to the maximum (Mean BBS weak to moderate correlations with the other balance 53.75±1.65). The BBS has a ceiling effect and less measures, which are BBS and Cog-TUG. The correlation sensitivity in active older adults. When Narrow range coefficients ranged from 0.3 to 0.45, which indicating a BBS score at higher end of scale compared to the large weak to moderate correlation. range score of YBT (25 to 90), the relationship between One previous study by Lee D-k et al. in 2014 have this two variable may possibly show less correlation. In reported an insignificant correlation between YBT this study, we found 10 participant had 54 score on BBS, composite score and BBS score performance in older have achieved different distance on YBT and hence adults, which are in agreement with the present study the statistics shown weak to moderate correlation. The which shows statistical significant but weak to moderate testing of the BBS in active elder population may not be correlation between Cog-YBT and BBS score (r=0.369 sufficiently challenging to detect subtle balance deficits for Right leg, r=0.435 for Left leg; p<0.005) found in the or fall risk during the dual task, hence there is a need for present study 16. alternative fall predictor measure, such as the Cog-YBT. The BBS is an ordinal scale; however, the YBT score
Brauer et al. studied on 100 active older females is measured on a ratio scale. In addition, an advantage with a mean age of 73.0±5.0 years and concluded that of the Cog-YBT is, its ability to simultaneously assess the BBS results had shown a ceiling effect for older functional dual task performance, single leg standing Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 19
endurance, dynamic balance testing and training and documentation methods such as the Dynamic together with visual feedback on distance measure in Posturography or motion analysis with inertial sensors. different directions. Third, the sample size was small and majority of the participants were fell under the younger old group with In our study, we found that Cognitive Time Up mean age 64.7 ± 4.6 years. and Go (Cog-TUG) has significant weak correlation (r=-0.313 for Right leg, r=-0.0301 for Left leg, p<0.05, Future recommendation for making it verified as a CI=95%) with the Cog-YBT score. Cody L. et al. have potential screening test, further application with large analysed the concurrent validity of YBT-LQ to TUG and homogeneous group, different settings, comparison reported that YBT-LQ have significant correlation with with gold standards and conducting long term follow TUG (r=-0.52; p=0.003) which shows some variability up or prospective cohort studies willallow the analysis with current study results 16. Furthermore, Y. Tong had of specificity, sensitivity, predictive values, and false done prospective study on Cog-TUG as fall predictor results. in community dwelling elder and reported that fall is Though the reliability of the cognitive Y Balance significantly correlated with Cog-TUG with statistical test is high in our context, the concurrent validity of this weak correlation (r=0.341, p=0.009) 27. Barry E. has test is not adequate to use it as a fall predictor measure stated that falls assessment is a multi-factorial and his among the community dwelling elder. Moderate to high systematic review of diagnostic accuracy concluded concurrent validity with other balance evaluation tool or that it has limited predictive ability and should not be predictive validity must be required before the utilisation utilised as solely to discriminate community-dwelling as valid tool. older people at high risk of falls 28. Acknowledgement: In addition to this, our aim of study was to assess the intra-rater and inter-rater reliability of Cog-YBT in Conflict of Interest: The researchers claim no elders. Our statistical analysis showed that Cog-YBT conflicts of interest. demonstrated high intra-rater (ICC= 0.946 for right leg, ICC= 0.959 for left leg) and inter-rater reliability Author Contributions (ICC=0.908 for right leg, ICC= 0.944 for left leg) with Conceptualization, AG, DD; Data collection, older adults. This was the first study to demonstrate AG; Funding acquisition, AG; Investigation, AG; this two reliability of cognitive variation of YBT. It is Methodology, AG, DD ; Project administration, AG; interesting to say that the majority of elders are quick Supervision, AG, DD; Writing_ original draft, AG; balance adaptor and have improved performance in data Writing, review & editing, AG, DD. collection session, than they had performed in trialof Cog-YBT. The Funding Source: We have not received any funding for this research. Several previous published studies which have utilized YBT as a balance measure in elder population Refrences (Lee D.K. 2015; Shin & An, 2015; Sarvestani et al., 1. Jennifer Stewart Williams, et al. Prevalence, risk 2012) have reported no incidence of falls or injuries factors and disability associated with fall-related during YBT performance. In the current study also, there injury in older adults in low- and middle-income was no fall incidence happened during testing. Taken countries: results from the WHO Study on global altogether these studies, we can say that Cog-YBT is a Ageing and adult health (SAGE). BMC Medicine. safe balance measure in independent elders. 2015;13:147 There were some limitations in this study. First, 2. Murray CJL, et al. Disability-adjusted life years the documentation of validity and reliability are (DALYs) for 291 diseases and injuries in 21 specific to rural community of Gujarat and Gujarati regions, 1990–2010: a systematic analysis for the elderly populations. Second, we didn’t compare the Global Burden of Disease Study 2010. Lancet. 2012; 380:2198–227. cognitive YBT to gold standard balance evaluation 20 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
3. Majumi M. Noohu MPTh, et al, Relevance of to Predict Falls in Community-Dwelling Older balance measurement tools and balance training for Adults: A Systematic Review. Published by fall prevention in older adults, journal of clinical Elsevier Ltd.; 2016; 102(1):29-40. doi: 10.1016/j. gerontology and geriatrics. Volume 5, Issue 2, June physio.2015.04.011. PMID: 26390824 2014, Pages 31-35. 15. Pardasaney PK, Latham NK, Jette AM, Wagenaar 4. J.T. Chang, S.C. Morton, L.Z. Rubenstein, RC, Ni P, Slavin MD, & Bean JF. Sensitivity W.A. Mojica, M. Maglione, M.J. Suttorp, et al, to change and responsiveness of four balance Interventions for the prevention of falls in older measures for communitydwelling older adults. adults: systematic review and meta-analysis of Physical Therapy, 2012; 92(3), 388-97. randomised clinical trials, BMJ, 2004; 328, p. 680 16. Lee D-K, Kang M-H, Lee T-S, Oh J-S , Relationships 5. M. Matarese, D. Ivziku, F. Bartolozzi, M. Piredda, among the Y balance test, Berg Balance Scale, M.G.De Marinis, Systematic review of fall risk and lower limb strength in middle-aged and older screening tools for older patients in acute hospitals, females. Braz J Phys Ther. 2015; 19(3):227-234. Journal of Advance Nursing, 2015 Jun;71(6):1198- http://dx.doi.org/10.1590/bjpt-rbf.2014.0096 209. doi: 10.1111/jan.12542. Epub 2014 Oct 7. 17. Phillip J. Plisky et al, “The Reliability of an 6. J. Lee, A.I. Geller, D.C., Strasser Analytical review: Instrumented Device for Measuring Components of focus on fall screening assessments. P M R, 2013; the Star Excursion Balance Test” North American 5, pp. 609-621. Journal of Sports Physical Therapy, 2009, Volume 7. Seong-Hi Park1 et al, Tools for assessing fall risk in 4, Number 2. the elderly: a systematic review and meta-analysis, 18. Cody L. Sipe1, Kevin D. Ramey1, et al. The Y Springer International Publishing Switzerland, Balance Test Lower Quarter is a Valid and Reliable Aging Clin Exp Res 2018 Jan; 30(1):1-16. Assessment in Older Adults, Journal of Aging and 8. Jennifer Muhaidat, PhD, Andrew Kerr, PhD , Physical Activity, 2019; 27(5):663–669. Jonathan J. Evans, PhD , Mark Pilling, PhD, 19. Steffen T, Hacker T, Mollinger L, Age- and Validity of Simple Gait-Related Dual-Task Tests gender-related test performance in community- in Predicting Falls in Community-Dwelling dwelling elderly people: six-minute walk test, Older Adults. Archive of physical medicine berg balance scale, timed up go test, and gait and rehabilitation, Published: September 25. speeds. Physical Therapy. 2002; 82(2):128-137. DOI:https://doi.org/10.1016/j.apmr.2013.07.027 20. Ann Medley &Mary Thompson , Usefulness of 9. Zijlstra A., Ufkes T, Skelton D.A, Lundin-Olsson Variations of the Timed Up and Go in Apparently L, Zijlstra W, Do dual tasks have an added value Healthy Individuals. Physical & Occupational over single tasks for balance assessment in fall therapy in Geriatrics. 2009, Volume 23, 2005- prevention programs? A mini-review. Gerontology Issue 4. 2008; 54: 40-49 21. Shumway-Cook, A., Brauer, S., & Woollacott, M. 10. Yamada M., Aoyama T, Arai H. et al, Dual-task Predicting the probability for falls in community- walk is a reliable predictor of falls in robust elderly dwelling older adults using the timed up & go test. adults. J Am Geriatr Soc. 2011; 59: 163-164 Physical Therapy, 2000; 80(9), 896-903. 11. Alsaif AA, Alsenany SA. Balance and Prevention 22. N., Pam M.S. DUAL-TASK PERFORMANCE. of falls among the Elderly. MOJ Gerontology & Psychology definitions, April 7, 2013. Geriatrics. 2018; 3(3):1-6. PsychologyDictionary.org 12. I P Donald 1, C J Bulpitt. The Prognosis of falls in 23. Susan B. O’Sullivan, text book of Physical Elderly People Living at Home. Age Aging, 1999; Rehabilitation. 6th edition. 2014. 28(2):121-5. doi: 10.1093/ageing/28.2.121. 24. Ruth Ann Mathis et al., Reliability and Validity of the 13. S.R. Lord, R.D. Clark, I.W. Webster Postural Patient-Specific Functional Scale in Community- stability and associated physiological factors in a Dwelling Older Adults, Journal of GERIATRIC population of aged persons, J Gerontol Med Sci, Physical Therapy, 2019; 42(3):E67-E72 1991; 46, pp. M69-M76 25. Brauer SG, Burns YR, Galley P., A prospective 14. Muir-Hunter SW, Wittwer JE. Dual-task testing study of laboratory and clinical measures of postural Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 21
stability to predict community-dwelling fallers. 27. Y. Tong et al., Cognitive dual-task Timed-Up-and- The journals of gerontology. Series A, Biological Go test as a predictor of falls in the community- sciences and medical sciences, 2000; 55(8):M469- dwelling elderly. Journal of Science and Medicine 76. in Sport. JSAMS. (2018-11); 21(1):S80-S81 26. Newton RA., alance screening of an inner city older 28. Barry E. et al., Is the Timed Up and Go test a adult population. Archives of Physical Medicine useful predictor of risk of falls in community and Rehabilitation. 1997; 78(6):587-91. http:// dwelling older adults: a systematic review and dx.doi.org/10.1016/S0003-9993 (97)90423-8. meta-analysis. BMC geriatrics. 2014; 14(1):14. PMid: 9196465 22 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13822 Type of manuscript- Review article Water, Sanitation and Hygiene Challenges Faced in India in COVID-19 Prevention: A literature Review
Anne Praveena Rani1, Florence Elizabeth R2, Mahesh Maria Nathan3 1Research Associate, Water, Sanitation and Hygiene (WASH) Department, World Vision India, 2Knowledge Management Specialist, Water, Sanitation and Hygiene (WASH) Department, World Vision India, 3Director - Water, Sanitation and Hygiene (WASH) Department, World Vision India
Abstract Coronavirus disease 2019 (COVID-19) is a respiratory infection. This is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 was first found in Wuhan, China on December 2019.1 On 11 March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic.2 Currently, India ranks second in COVID-19 cases. There is no proven specific treatment for the infection.3 Infection Prevention and Control (IPC) through Water, Sanitation and Hygiene (WASH) and frequent Hand Washing with Soap (HWWS) is the key in stopping the spread of COVID-19.4 This paper, using secondary data sources discusses on challenges faced in the country in adopting WASH practises to prevent COVID-19. Besides social distancing and other hygiene protocols, HWWS is a simple and primary preventive measure to combat COVID-19 but face challenges due to water unavailability or low access to water. Poor sanitation and hygiene plays a role due to lack of water and awareness. Ensuring clean access to water, good sanitation and improved hygiene practices in the communities and health care facilities will prevent COVID-19 transmission. Policies on water management, water conservation will address the issue of water challenge, which not only will help in addressing COVID-19 transmission but in the days to come. An intensive social behavioural change programme to be conducted at various levels to eradicate myths associated with COVID-19.
Keywords: COVID-19, Water, Sanitation and Hygiene, infection, prevention.
Introduction density is 384 persons per square kilometre. Asia’s largest slum Dharavi with 3,35,907 persons per square According to WHO, Novel coronavirus disease kilometre highly associated with the COVID-19 due to (COVID-19) is caused by SARS-CoV-2, first occurred the population crowd.7 About 58.2% of the households 5 in Wuhan China. COVID-19 has affected 216 countries in rural households in India have drinking water facilities 6 and has infected over 9 million people, globally. In outside the premises, where people go out for water. India, among the population of 1.366 Billion, about 1.8 This can be a chance of transmission during COVID-19. million cases were confirmed by August 3, 2020 which Similarly, for households that have latrine facilities has 6,07,384 active cases and 41,585 deaths as on August outside the premises.8 India with extreme water stress 7, 2020, according to Ministry of Health and Family makes it difficult to practice handwashing and hygiene Welfare (MoHFW). In India, the average population during COVID-19. Providing safe water, sanitation and hygienic conditions is very essential for preventing the infectious disease outbreaks, including COVID-19. Corresponding author: Anne Praveena Rani A Methodology (Source Selection Criteria): Research Associate, Water, Sanitation and Hygiene (WASH) Department, World Vision India, COVID-19 related documents published until Phone- 08754712388, Mail id- Anne_Rani@consultant. July 2020 were extracted from various databases like wvi.org PubMed Central (PMC) / MEDLINE, The Lancet, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 23 and ResearchGate. The search terms for each online asymptomatic individual to others.12 The lack of access database containing COVID-19 disease, SARS-CoV-2 to water directly or indirectly contributes COVID-19 virus, COVID-19 India published until July 2020 transmission. were included. Other sources include WHO and the Open Defecation and Waste Water Management: Government of India websites. In India, according to the NSS 76th round report, 41% Results of households use community bathrooms, 11.2% use community latrines and 20.2% have no latrines. People WASH Challenges in COVID-19 Prevention: from households without toilets are most likely to Low Access to Water: Access to water is a defecate in the open, which may contribute to the risk key determinant for infectious disease control and of transmission of COVID-19 through the faecal-oral prevention.9 route due to open defecation. To improve sanitation, government built more than 100 million toilets through Handwashing with Soap (HWWS) at critical times Swachh Bharat Mission (SBM). However, many of is one of the precautions to prevent any infectious them remain unconnected to a proper sewer system. diseases. The WHO recommends frequent HWWS as In addition, there are not enough treatment plants to a preventive measure against COVID-19 transmission handle all the sewage. Vulnerable communities have 10 along with social distancing. According to World water and sanitation services where people gather in Resources Institute (WRI) reports, India in 13th rank groups, increasing the risk of COVID-19 transmission. out of 17 countries on the list of extremely high water All community sanitation facilities cause risk as it stressed countries in the world. According to NITI makes social distancing and hygiene difficult. The Aayog, nearly 600 million people in India face extreme presence of poorly maintained mega community toilets water stress. Frequent hand washing per person, ten and open defecation due to lack of access to toilets are times a day consumes around 20 to 40 litres of water and major contributors to COVID-19 cases especially in a family of five members would need 100 to 200 litres. urban slums and rural parts of the country, according to This increases the demand for water, where the country Ministry of Health and Family Welfare- Drinking water, already faces extreme high water stress conditions, sanitation and Housing condition in India. making difficult for the people to practice HWWS as per recommendations.11 Lack of Hygiene: According to NFHS-4 (2015- 16), only 24% households have access to both soap and Women and girls bear most of the responsibility in water as per. NSS say that only 36% of Indians wash managing water at the household level, collecting water their hands with soap before a meal.13 A study revealed from the source to the point of use. The demand for an average level of awareness on HWWS and hygienic water during this COVID-19 has indeed increased the practices among doctors and nurses and recommended burden on women and girls in collecting water. for regular training to health care professionals on infection prevention and control. The health care According to National Sample Survey’s (NSS) professionals mentioned lack of handwashing facility or 2018 report, nearly 48.3% of the households in urban unavailability of alcohol based hand rub as challenge in and rural India do not have exclusive access to drinking following hand hygiene practice.14 water. One-fourth of these households (23.6%) access it through a public, unrestricted source as per. About 30.5% Lack of Awareness: In India, lack of awareness, of rural households access public community sources. It knowledge and negligence of COVID-19 as one of is also reported that in most of the community sources, the main contributing factors for fast transmission of people do not follow social distancing principles. A COVID-19 transmission.15 A recent survey found many study revealed viral contamination in air samples, on misconceptions in people about the COVID-19 spread. frequently touched surface points and surfaces such as Some of the misconceptions are virus (COVID-19 toilets. Touching the water, faucets by many individual infection) cannot affect the country due to its warm can transmit COVID-19 from pre-symptomatic or or hot weather, infection affects only people above 60 24 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
years of age. The results showed majority of the study The pandemic COVID-19 has substantially affected participants used masks while going out, however, about Indian labour. After the strict lockdown, the country 40% of these participants did not believe wearing a mask has begun unlock which could be a threat in a resource in reducing COVID-19 spread. This superstitious beliefs poor settings like India with limited WASH services and due to lack of education, awareness and ignorance will practices. The Ministry of Health and Family Welfare has lead to increase in infection transmission.16 A study released guidelines to be followed in unlock. Guidelines conducted in India about knowledge, attitude and being followed vehemently is dubious. anxiety during COVID-19, reported that the sources for COVID-19 information were through televisions, Conclusion and Recommendations social media and through Arogya Setu application The main challenge of access to Water, Sanitation recommended by Government of India. The result and poor Hygiene practices need to be addressed to showed, study respondents had a moderate level of combat the spread of COVID-19 infection. Addressing knowledge on COVID-19 virus transmission and the the challenge will help to control outbreak of any 17 risks of getting serious COVID-19 illness. COVID-19 infectious diseases. To improve water and sanitation, awareness to the communities, health care workers is government has brought in many programmes and most needed to reduce the transmission. schemes like Jal Shakti Abhiyan, Jal Jeevan Mission; Atal Bhujal Yojana, Swachh Bharat Mission. These Discussion schemes or programmes mainly focused on supply side, From the above findings, we see that there is infrastructure approaches with limited implementation humongous challenge of WASH services and practices capacity. Capacity development and ownership from existing in the country. This challenge pose a greater risk the community is still lagging. The priority on water for overly populated country like India with a population conservation is to be emphasized much and simple of 1.3 billion people with a population density of 455 rainwater harvesting at household level will eliminate person per sq. km population density according to water crisis. the World Bank data, compared to the global average The country do not have adequate wastewater population density of 25 persons per sq.km. Ensuring treatment plants. Treated water can reduce the use of hygiene and sanitation in a densely populated and fresh water, which can reduce the consumption of fresh resource poor settings like India remains a challenge. water significantly. Investing in sustainable solutions Most people living in rural communities and urban slums for wastewater treatment will reduce future water crisis, depend on community water sources and toilets. During help in adopting to good WASH practices. Alongside, the time of COVID-19, many governmental and non- much efforts needed in increasing hygiene awareness in governmental organisations have increased access to people. A strong behaviour change programme is needed community drinking water, handwashing station with to every citizen to make them realise the importance soap and community toilets. Yet again, the challenge is and their role in contributing to water conservation; observed in regular maintenance of these infrastructures management; hygiene practices for infection prevention due to lack of water and lack of interest from community. control and better quality of life. Unregulated and free access to groundwater Source of Funding- Self-Funding extraction has resulted in over exploitation of groundwater and reduced ground water levels. Scanty Ethical Clearance- Not Applicable and inconsistent rainfall, limited sources of surface water add up to the water stress condition. Due to these References factors, both rural and urban population have limited 1. Lai C-C, Shih T-P, Ko W-C, Tang H-J, Hsueh P-R. access to water and people face challenges to adopt to Severe acute respiratory syndrome coronavirus good WASH practices. The demand for water has yet 2 (SARS-CoV-2) and coronavirus disease-2019 increased the challenges during COVID-19. (COVID-19): The epidemic and the challenges. Int J Antimicrob Agents. 2020 Mar;55(3):105924. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 25
2. Cucinotta D, Vanelli M. WHO Declares COVID-19 PMC7263456/ a Pandemic. Acta Biomed. 2020 19;91(1):157–60. 11. Grant S, Saphores J-D, Feldman D, Hamilton A, 3. Cunningham A, Goh H, Koh D. Treatment of Fletcher T, Cook P, et al. Taking the “Waste” Out COVID-19: Old tricks for new challenges. Critical of “Wastewater” for Human Water Security and Care. 2020 Dec 1;24. Ecosystem Sustainability. Science (New York, 4. Alzyood M, Jackson D, Aveyard H, Brooke NY). 2012 Aug 10;337:681–6. J. COVID‐19 reinforces the importance of 12. Santarpia J. Transmission Potential of SARS- handwashing. J Clin Nurs [Internet]. 2020 May 14 CoV-2 in Viral Shedding Observed at the University [cited 2020 Oct 14]; Available from: https://www. of Nebraska Medical Center. :12. ncbi.nlm.nih.gov/pmc/articles/PMC7267118/ 13. Kamath S, Kamath R, Salins P. COVID-19 5. Cucinotta D, Vanelli M. WHO Declares COVID-19 pandemic in India: challenges and silver linings. a Pandemic. Acta Biomed. 2020 19;91(1):157–60. Postgrad Med J. 2020 Jul;96(1137):422–3. 6. Teboh-Ewungkem MI, Ngwa GA. COVID-19 in 14. To assess the knowledge and compliance on malaria-endemic regions: potential consequences hand hygiene among staff nurses working in for malaria intervention coverage, morbidity, and selected community health centers: descriptive mortality. The Lancet Infectious Diseases [Internet]. cross-sectional research design - MedCrave 2020 Sep 21 [cited 2020 Oct 14];0(0). Available online [Internet]. [cited 2020 Oct 14]. Available from: https://www.thelancet.com/journals/laninf/ from: https://medcraveonline.com/NCOAJ/to- article/PIIS1473-3099(20)30763-5/abstract assess-the-knowledge-and-compliance-on-hand- 7. Mishra SV, Gayen A, Haque SM. COVID-19 and hygiene-among-staff-nurses-working-in-selected- urban vulnerability in India. Habitat Int. 2020 community-health-centers-descriptive-cross- Sep;103:102230. sectional-research-design.html 8. Naddeo V, Liu H. Editorial Perspectives: 2019 15. Pandey S, Gupta A, Bhansali R, Balhara S, Katira novel coronavirus (SARS-CoV-2): what is its P, Fernandes G. Corona Virus (COVID-19) fate in urban water cycle and how can the water Awareness Assessment -A Survey Study Amongst research community respond? Environ Sci: Water the Indian Population. 2020 Apr 1;1–10. Res Technol. 2020 May 7;6(5):1213–6. 16. Feng S, Shen C, Xia N, Song W, Fan M, Cowling 9. Anim DO, Ofori-Asenso R. Water scarcity and BJ. Rational use of face masks in the COVID-19 COVID-19 in sub-Saharan Africa. J Infect. 2020 pandemic. Lancet Respir Med. 2020 May;8(5):434– Aug;81(2):e108–9. 6. 10. Brauer M, Zhao JT, Bennitt FB, Stanaway JD. 17. Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Global Access to Handwashing: Implications for Kaushal V. Study of knowledge, attitude, anxiety COVID-19 Control in Low-Income Countries. & perceived mental healthcare need in Indian Environ Health Perspect [Internet]. 2020 May population during COVID-19 pandemic. Asian J 15 [cited 2020 Oct 14];128(5). Available from: Psychiatr. 2020 Jun;51:102083. https://www.ncbi.nlm.nih.gov/pmc/articles/ 26 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13823 Assess the Effectivness of Training Programme on Auxiliary Nurse Midwives Related to New Born Care
Anu Gauba1 , Maharaj Singh2 1PhD Scholar, Department of Nursing, NIMS University, Jaipur, 2Professor& Research Head, Department of Nursing, NIMS University, Jaipur
Abstract Background- Many newborns fall sick in the first days of life due to complications of childbirth. It is therefore important to have skilled care at birth so that any complications can be prevented or treated. Objectives-1) To compare the practices of ANMs with regard to new born care before and after the administration of training programme.2) To determine the association between the practice scores and the selected demographic data i.e. age, years of experience and education. Method - A Pre experimental design that is one group pre test and post test design was adopted in the study. A training programme was developed by the researcher and administered to the participants. Results- The mean scores of pre test were 22.06 and standard deviation 2.0. The mean of post test knowledge scores were 40.5 and standard deviation 3.2 and found to be significant at 0.05 levels. The inference was drawn that age, years of experience and educational status had no association with post test scores. Conclusion – The training programme was found to be very effective in improving the practices of Auxiliary nurse midwives.
Key words: ANMs, Training programme, Newborn care.
Introduction to show that Auxiliary nurse midwives and other community health workers, when appropriately trained, The high rates of preventable death and poor supplied, supported and supervised, can identify and health and well-being of newborns and children under correctly treat most children for pneumonia, diarrhea the age of five are indicators of the uneven coverage and malaria 3, 4. Community management of childhood of life-saving interventions and, more broadly, of illness is an important contribution to the remarkable inadequate social and economic development. Poverty, progress in reducing child mortality. Globally, the rate of poor nutrition and insufficient access to clean water under–five mortality has decreased by nearly half, from and sanitation are all harmful factors, as is insufficient 90 deaths per 1000 live births in 1990 to 46 in 20135. access to quality health services such as essential care for newborns. Health promotion, disease prevention Material and Methods services (such as vaccinations) and treatment of common childhood illnesses are essential if children are to thrive The study was conducted in Primary Health as well as survive1. Many newborns fall sick in the first Center (PHC) Tigaon, Faridabad. In present study, a days of life due to complications of childbirth. It is Pre experimental design that is one group pre test and therefore important to have skilled care at birth so that post test design was adopted in order to achieve the any complications can be prevented or treated 2. There objectives. The sample comprised of 20 Auxiliary nurse is ample evidence from research and implementation midwives of selected community. The purpose of the study was explained to the subjects, the confidentiality of the responses was assured & consent of the subjects Corresponding Author: was taken prior to the conduct of the study. The data Ms Anu Gauba was collected by using structured questionnaire, which [email protected] consists of two parts. Part I includes Demographic Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 27
Profile of ANM’s which contained 3 items, i.e. Age, were 40.5 and standard deviation 3.2. The “t” value Years of experience and Educational status. Part II was computed and found to be 3.3 which is significant includes Questionnaires related to newborn care. Tool at 0.05 levels. (Table no -1). This shows that there is translated into local language i.e. Hindi. Pre test was significant difference between the mean of Pre test was administered on the Day 1. Training was given to and post test scores of ANMs. The structured training ANM’s for 2 days followed by demonstration i.e. Steps programme on newborn care was effective in improving of hand washing and Measuring of weight of baby by the knowledge of ANMs (Fig no- 1). Fisher exact test using spring balance. The inputs were evaluated by using was computed to find out the association between post descriptive and inferential statistics. To find out the test scores with selected variables i.e. age, years of significance difference between; mean pre-test and post experience and education status of ANM’s. Fisher exact test scores of ANM’s paired t- test value was calculated. value with respect to age comes out to be 0.50, which is Fisher exact test was applied to find association of scores not significant at 0.05 levels. This indicated that post test of group with selected demographic data. practice scores had no association with age of ANM’s. Fisher exact value with respect to years of experience Results comes out to be 0.42, which is not significant at 0.05 Study revealed that 87% of ANM’s belonged to the levels, which shows that post test practice scores had no age group of 30-40 years, 13% belonged to the age group association with years of experience Fisher exact value of 40-50 years. With regard to years of experience 47% with respect to education comes out to be 0.10, which is of ANM’s were having 3-4 years of experience, 53% not significant at 0.05 levels. This indicated that post test were having 5-6 years of experience. With regard to the practice scores had no association with education. The educational status of the ANM’s 27% were educated inference was drawn that age, years of experience and up to secondary level and 73% were educated up to sr. educational status of ANM’s had no association with secondary. The mean scores of pre test were 22.06 and post test scores. standard deviation 2.0. The mean of post test scores
Table -1: Mean, standard deviation and ‘t’ value of pre- post test scores of ANM’s
Group Pre test Post test ‘t’ value df p value
Mean SD Mean SD ANM’s (n=20 22.06 2.0 40.5 3.2 3.3 14 0.02*
*t (14) = 2.15, p < 0.05, *Significant at 0.05 level
Data in table – 1, shows that the mean scores of pre test was 22.06 and standard deviation was 2.0, whereas the mean of post test practice 40.5 and standard deviation was 3.2. The‘t’ value was computed and found to be 3.3 which is significant at 0.05 level. 28 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Fig – 1 Diagram showing the pre test and post test mean and standard deviation.
Discussion results were very good 64(64.45%), good 31(31.31%), average 4(4.04%) which indicates that training Auxiliary nurse midwives play a pivotal role in programme was very effective.7 Similarly Upul et al the health status of a rural population due to their close planned a 4 day training programme among health care and continuous contact with the rural community. providers. Results revealed that there was a signifi cant Moreover, due to shortage of adequate health facilities improvement in umbilical cord care practices at home in rural India, ANM’s have become a central fi gure in following the intervention. Application of surgical helping the community to identify and meet their health spirit, on umbilical card has declined from 71.5% in needs (WHO 2000). However, health workers in many the pre-intervention to 45.3% in the post intervention developing countries are poorly motivated, inadequately (P<0.001)8. trained and hence are unproductive. We found that the knowledge and skills of Auxiliary nurse midwives Conclusion varies drastically. We also found that if their skills The delivery of primary and preventive care, ANM’s were poor then their performance in terms of maternal may facilitate improvements in health status and quality services and child health services were also limited. of life in rural communities. These impacts can be Similarly, Chandra DM, Naik VA also conducted greatly increased when ANM’s are fully integrated into training for two days which included topics on breast the primary care team, working alongside physicians, feeding and newborn care practices. The study reveals nurses, and other clinic staff. Incorporating ANM’s that before interventions knowledge about newborn care into the healthcare team frees up resources and enables services provided by the TBA’s were poor where as rural healthcare professionals to focus on more complex post-test evaluation showed that there was a progressive patients and issues. So, we concluded that the practices improvement in the newborn care services. 6 Similar of ANM’s is a crucial aspect of health systems affecting to this study Susham et al assessed the effectiveness the coverage of community-based newborn health care of training course on Infant feeding practices at Rural programmes, as well as adherence to essential newborn Teaching Hospitals. The pre test scores were found to care practices at household level. be very good 3(0.03%), good 65(65.66%), average28 (28.28%), below average 3(3.03%). And the post training Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 29
Acknowledgements We are very thankful to all the pmed.1000340. Medline:20877714 participants who gave their consent to participated in 5) UN Interagency group for child mortality the study. estimation. Report 2014. Levels and trends in child mortality. New York: UNICEF, 2014. Source of Support: None Available at: http://www.childmortality.org/ Conflict of Interest: Nil files_v17/download/UNICEF%202014%20 IGME%20child%20mortality%20Report_Final. References pdf. Accessed: 1 October 2014 6) Chandra M, Naik A, Wantamutte S, Mallapur D. 1) https://www.who.int/health-topics/newborn-health Impact of training of traditional birth attendants 2) https://www.who.int/maternal_child_adolescent/ on the newborn care. Indian J Paediatrics. January news/events/2012/CHW_Manual.pdf 2009; 76(1): 33-36. 3) George A, Menotti EP, Rivera D, Montes I, Reyes 7) S Susham,D Amol , H Samir , M Suresh , Y Arun. CM, Marsh DR. Community case management Effectiveness of the training course of ASHA on of childhood illness in Nicaragua: Transforming Infant feeding practices at a rural teaching hospital, health systems in underserved rural areas. J Health a cross sectional study. Journal of critical and Care Poor Underserved. 2009;20(4):99-115. diagnostic research (internet) 2012. (Cited on 2012 Medline:20168036 doi:10.1353/hpu.0.0205 June 20): p 1-3. 4) Yeboah–Antwi K, Pilingana P, Macleod WB, 8) Upul Senarath ,Dulitha N, Fernando Ishani Semrau K, Siazeele K, Kalesha P, et al. Community Rodrigo. Newborn care at home: Effect of hospital case management of fever due to malaria and based intervention in srilanka. J Trop Pediatr. April pneumonia in children under five in Zambia: 2007;53 (2):113-118. A cluster randomized controlled trial. PLoS Med. 2010; 7:e1000340. doi:10.1371/journal. 30 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13824 A Cross Sectional Study on Tobacco usage among rural adult population of Davangere, South India
Arun Daniel J1, Madonna J Dsouza2, Pragati Chavan 1Associaate professor, Department of Community Medicine, Aarupadai Veedu Medical College, Puducherry, 2Assisstant Professor, Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, 3Professor, Department of Community Medicine, SS Institute of Medical Sciences and Research, Davangere
Abstract Background: Usage of both smoking as well as smokeless form of tobacco has risen in both urban and rural areas of Davangere estimating to a prevalence of 30.7% on average, with highest prevalence of 39.6% among rural males.
Objective: To study the prevalence, pattern and socio-demographic factors influencing Tobacco usage among adult population in rural field practice area of SSIMS&RC, Davangere
Methodology: A cross-sectional study was conducted from July to September 2014 among adult population aged 18 years and above selected systematically till an estimated sample size of 450 individuals was obtained. Demographic data and details on tobacco usage were recorded using a pre-tested, semi-structured questionnaire by interview method. Data entry and analysis was done using SPSS trial version 20.1. Chi square (χ2) test and Multiple Logistic regression analysis were applied to see the interaction of socio- demographic variables on tobacco usage.
Results: Among the study participants, 64.2% (n=289) used some form of tobacco. Men (53.3%, n=230) used tobacco more than females (13.1%, n=59) (p<0.001). Among the tobacco users (n=289), majority of men used smoking forms of tobacco (92.2%, n=212) like bidis (78.7%, n=181) and cigarettes (13.5%, n=31) whereas majority of women used smokeless forms of tobacco (96.6%, n=57) like tobacco leaves (91.5%, n=54) and gutka (5.1%, n= 3). Age group 20-35 years (OR= 1.2, p=0.01), male gender (OR= 4.4, p<0.001), illiteracy (OR= 3.5, p<0.001), agricultural occupation (OR= 2.2, p<0.001), higher socio-economic status (class II) (OR= 1.6, p=0.05) and family history of smoking (OR= 2.5, p<0.001) were the factors significantly associated with tobacco usage.
Conclusion: Smoking form of tobacco especially bidis are widely used by young males in rural areas which demand focus of anti-tobacco policies of India on bidis in anti-tobacco campaigns.
Keywords: Tobacco usage, smoking and chewable tobacco, bidis
Introduction cautioning the need for rigorous preventive measures. (1) According to NFHS-III, in India, 55.8% male, Tobacco-attributable health expenditures are 16% 10.8% female in the age group of 12 to-60 years have higher than the tax revenue from tobacco to the country been consuming tobacco. Among males, 32.7% were smokers and 36.5% were tobacco chewers, while among Corresponding author: females, it was 1.4 and 8.4%, respectively.(2) Usage of Dr. Arun Daniel J Department of Community Medicine , both smoking as well as smokeless form of tobacco has Aarupadai Veedu Medical College, Pondicherry been on rise in both urban and rural areas of Davangere Phone (or Mobile) No.: +91-9894236074 estimating to a prevalence of 30.7% on average, with Email: [email protected] highest prevalence of 39.6% among the rural males. (3) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 31
Any attempt to intervene against the growing tobacco Age group 20-35 years (OR= 1.2, p=0.01), male gender menace will not be fruitful without proper understanding (OR= 4.4, p<0.001), illiteracy (OR= 3.5, p<0.001), of the pattern and factors influencing tobacco usage. agricultural occupation (OR= 2.2, p<0.001), higher Therefore, this study aimed to study the prevalence, socio-economic status (class II) (OR= 1.6, p=0.05) and pattern and socio-demographic factors influencing family history of smoking (OR= 2.5, p<0.001) were the Tobacco usage among adult population in rural field factors significantly associated with tobacco usage. practice area of SSIMS&RC, Davangere. Discussion Materials & Methods The usage of tobacco among the males (79.6%) A cross-sectional study was conducted from July and females (20.4%) was comparatively higher than to September 2014 in the rural field practice area of the national average (males: 55.8%, Females: 10.8%, SSIMS&RC, Davangere, Karnataka State, South NFHS-III).(2) Higher proportions of tobacco usage in India among adult population aged 18 years and above our study population can be attributed to poor awareness selected systematically till the calculated sample size regarding hazards of tobacco or a callous attitude of 450 individuals was obtained viz: every 4th house towards quitting tobacco as it is evident from the lower was selected and one individual aged 18 years or above quit rates among the female tobacco users (5%). More present in the house during the time of interview was males reported Bidi (tobacco wrapped in temburini picked randomly and interviewed using a pre-tested, leaf) smoking (78.7%) which was higher compared to semi-structured questionnaire. Demographic data and a similar study conducted by Yadav K et al (4) which details on tobacco usage like chewable or smoking showed a bidi usage of 44.6% among rural males. A very form of tobacco used, age at initiation, years of usage, likely reason for this observation is the pricing strategy presence or absence of systemic diseases, other specific of these tobacco products. Bidis cost nearly one-tenth of addictions, family history of tobacco usage and reasons the cost of cigarettes. Further bidis are manufactured in for quitting or not-quitting were recorded. small scale industries with favourable existing policies and vigilant anti-tobacco campaigns do not address Statistical Analysis bidi usage with priority. The factors associated with Data entry and analysis was done using SPSS version tobacco usage like illiteracy, farmer by occupation, 19.1. Data is presented as proportions and percentages. higher socio-economic status, family history of smoking Chi square (χ2) test was applied to see significant suggest a traditional inheritance of tobacco trend among differences and association of various parameters with the wealthy yet illiterate agriculturists. This is further tobacco usage. Multiple Logistic regression analysis was evident from the lower age of initiation among the males performed to see the interaction of certain independent (10-20 years, 39.6%) which is a little higher compared (5) variables on tobacco usage. to that reported by Joshi et al showing 52% initiated tobacco usage at 25-30 years of age. Results Conclusion The Mean age of the study participants was 47.16± 14.13, comprising 61.3% (n=276) of males. Majority The study showed a wider usage of smoking form of the participants were illiterates (33.5%, n=151) of tobacco especially bidis by young males in rural areas and farmers (60%, n=270) by occupation. Among the driven by social factors like illiteracy, higher socio- study participants, 64.2% (n=289) used some form of economic status and familial behaviour. This demands tobacco. Men (53.3%, n=230) used tobacco more than the focus of anti-tobacco policies of India on bidis in females (13.1%, n=59) (p<0.001). Among the tobacco anti-tobacco campaigns and well-structured behaviour users (n=289), majority of men used smoking forms of change communication strategies at individual, family tobacco (92.2%, n=212) like bidis (78.7%, n=181) and and community level. cigarettes (13.5%, n=31) whereas majority of women Acknowledgement: Special thanks to all interns of used smokeless forms of tobacco (96.6%, n=57) like Department of Community Medicine, S.S Institute of tobacco leaves (91.5%, n=54) and gutka (5.1%, n= 3). 32 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Medical Sciences who helped during this study. Available from: http://www.rchiips.org/nfhs/ factsheet.shtml Funding: No funding Source 3. Basanagouda K Patil. A community-based study Conflict of Interest: None declared on Tobacco use in Davangere Taluk-Karnataka. [Davangere]: RGUHS; 2009. Ethical approval: The study was approved by the 4. Yadav K, Anand K, Gupta V. Patterns of tobacco
Institutional Ethics Committee use across rural, urban, and urban-slum populations in a North Indian community. Indian Journal of References Community Medicine. 2010;35(2):245. 1. John RM, Sung H-Y, Max W. Economic cost of 5. Joshi U, Modi B, Yadav S. A study on prevalence tobacco use in India, 2004. Tob Control. 2009 Apr of chewing form of tobacco and existing quitting 1;18(2):138–43. patterns in urban population of Jamnagar, 2. Ministry of Health & Family welfare. National Gujarat. Indian Journal of Community Medicine. Health and Family Survey III, India. [Internet]. 2010;35(1):105. Government of India; [cited 2014 Dec 25]. DOI Number: 10.37506/ijphrd.v12i1.13827 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 33 Hidden Subjective Aspects in the Law of Diminishing Marginal Utility: The Initial Bump and Limitations of Neuroeconomics
Asima Tripathy1, Rajat Kumar Pradhan2 1Post Graduate Department of Zoology and Microbiology, Bhadrak Autonomous College, Bhadrak , Higher Education Department (Govt. of Odisha), 2Post Graduate Department of Physics, Bhadrak Autonomous College, Bhadrak, Higher Education Department (Govt. of Odisha)
Abstract Laws have flaws and no law in sciences or humanities can be above the existence of exceptions and the possibility of improvisations till perfection is attained since both rationalism and empiricism have severe limitations. We take up the microscopics of the law of diminishing marginal utility to bring the hidden subjectivity in several key aspects of its formulation. On the basis of an experiment with 118 persons, we show for the first time that there is an initial bump in the marginal utility. We also comment on the limitations of neuroeconomics to influence consumer choices indefinitely and explain the decision-making process as a quantum measurement using psychophysical interpretation.
Keywords: Total Utility, Marginal utility, Subjectivity, psychophysical interpretation, Neuroeconomics
Introduction to the law are only too well known to be repeated here The law of diminishing marginal utility (DMU) is as but what we intend to focus on in this article is the loss old as economics itself and is regular textbook material arising out of the efforts at bringing in and maintaining in introductory courses1,2. Utility of a commodity is objectivity in a law whose subjective origins and defined as the pleasure or satisfaction derived bythe ramifications are only too apparent to be missed for too 4 consumer and marginal utility (MU) is the change in the long . satisfaction level with each additional unit consumed. The psychological aspects of this somewhat For a univariate (Total) utility function the MU universal law can be analyzed in further detail to give is and its diminishing nature would be us important new insights and to generalize it to apply fully captured by the negativity of its second derivative: to more broader situations than what it has so far been (Marshall 1961). Though usually presented as applied to5. Similarly, the claims of neuroeconomics in a monotonically decreasing function of a power law kind regard to influencing consumer choices in a deterministic (e.g. , it can indeed have interesting way can be analyzed in light of the learning ability of variations, provided we take into account certain factors conscious subjects who cannot be programmed to make which have been consistently neglected and deliberately definite decisions not favoring them or favoring the 3 overlooked by authors and researchers . Exceptions seller by external forces for long.
Materials and Methods
Corresponding author: Responses were sought through personal massaging Asima Tripathy and also though various official Whatsapp groups Post Graduate Department of Zoology and of Undergraduate and Postgraduate students in the Microbiology, Bhadrak Autonomous College, Bhadrak, Department of Physics of Bhadrak Autonomous Higher Education Department (Govt. of Odisha) . College, Bhadrak in the age group of 19 to 24 to the Email ID: [email protected] specific question: How do you rate your satisfaction bite 34 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 by bite up to 12 bites of your favorite fast food (Pizza, Only four male students and an equal number of Dosha, Chhenapoda or whatever) starting with an initial female students reported outright decrease after the first value of 10 (arbitrary units) with an allowed range of bite as the law of DMU states. For two male students it satisfaction 0 to 15 per bite? 46 out of the 56 respondents continued to increase even beyond the 4th bite while two (36 male and 20 female) gave their numbers in favor of of them reported constancy of satisfaction in every bite an initial bump in the first 3 to 4 bites before the decline. till 4th and then the decline. These data are summarized in the following table -1.
Table-1: Summary of survey-I regarding per-bite-satisfaction
Increase Increase No of Decrease Increase up to Increase up to Constant up up to 2nd beyond 4th Total students after 1st bite 3rd bite 4th bite to 4th bite bite bite
Male 04 07 10 11 02 02 36
Female 04 05 05 06 00 00 20
Total 08 12 15 17 02 02 56
Another set of 62 persons (38 male, 24 female) in the age group of 25 to 48 were given the same question, but now with the range changed to 0 to 15 starting with the value 01 in the first bite with the number of bites increased to 15. Now there was a dramatic increase of the marginal utility to reach the initial bump before the actual decline started. In most cases, the mean increment in per-bite-satisfaction was by 100% in the second bite and by 50% in the third and so on. We presume that the relaxation of the starting value to 01 (in place of 10 in the earlier group) led to this new set of data, but these cannot be neglected as they are trained physics teachers and research scholars having good deal of experience in data handling and graphs. This new set of data is represented in table-2 below.
Table-2: Summary of survey-II regarding per-bite-satisfaction
Increase Increase No of Decrease Increase up to Increase up to Constant up up to 2nd beyond 4th Total students after 1st bite 3rd bite 4th bite to 5th bite bite bite
Male 00 08 14 13 01 02 38
Female 00 06 09 08 01 00 24
Total 00 14 23 21 02 02 62 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 35
This study conducted among these 118 persons in Subjectivity in the definition of the unit two separate groups indicates an initial bump in the It has been recognized by Marshall that the definition marginal utility curve for small units such as bites which of the unit of the commodity is rather arbitrary6. But of course gets masked as we increase the unit size. We we wish to point out that the definition of the unit is of discuss each of the issues in the following sections by paramount importance in determining the exact nature of plotting the results on a normalized scale of initial value a continuous MU curve. Smaller the unit, more accurate 100. One interesting aspect worth mention here is the will be the features of the MU curve as a continuous fact that most of those who responded in accordance function of the variable (which may be taken as time). with the law of DMU explicitly stated their knowledge Thus, the most significant departure is the presence of of the law and thus exposed their biased judgment in the the initial bump, a slight increase to a peak, before the study. We queried them a second time stating that others monotonic decrease starts (Figure 1a-c). This means are getting an initial bump, to which they either agreed the bump in the total utility is sharper than previously or took recourse to existence of subjective variations! thought of.
In these figures we represent the MU curves taking Oscillatory marginal utility the unit of commodity to be respectively three bites, two When the MU reaches a certain threshold bites and one bite of pizza. The law of DMU is usually negative value aversion for the object halts any further stated in terms of whole units of commodity such as one consumption thereby ending one cycle of utility. Our pizza, two pizza etc. which hides finer details of the MU experience tells us that needs, even if fulfilled to the curve (Fig. 1a). If we measure the pleasure obtained in point of aversion, do return again and again driving units of bites of pizza, after the first bite the MU of next the subject to seek the object in successive cycles. The five to six bites contains a less prominent peak (Fig 1c) opinion of the respondents on the repetition of the same which vanishes if we take whole pizzas as unit (Fig. food after the elapse of 03 days, 06 days, 03 months and 1a). The key point to note here is that MU does not start 06 months was sought. Fig 2 (a-c) depict the scenario diminishing right away from the very first unit consumed where the starting MU and the peak MU decrease in if the unit is chosen for smaller units. subsequent cycles due to repetition at smaller intervals. However, there is an increase in the pleasure/satisfaction 36 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 level when the same experience is repeated at longer intervals. Fig 3 (a-c) depict the MU for the repetition after three months and six months from the beginning cycle. With the elapse of longer intervals the need grows and so does the satisfaction as evidenced by the increase in the initial and the peak MU values.
Fig. 2a: Cycle 1 :Start Fig. 2b: Cycle 2: 03 days later Fig. 2c: Cycle 3: Six days later
When we take the number of such cycles as in Fig. 3 along x-axis with the peak utility along y-axis we may get a typical curve like these having the characteristic peak in the beginning before showing the expected diminishing utility with time, while for the cases in Fig. 2 we get monotonically decreasing marginal utility as expressed in the traditional formulations of the law. Of course the units consumed obviously have an increase with time but the diminishing of marginal utility is now not with the units consumed per se, but with the increase or decrease of time interval between cycles of utilization/consumption/enjoyment.
Fig3a: Cycle 1:Start Fig3b: Cycle 2: 3 months later Fig3c: Cycle 3: Six months later Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 37
Having explored the cyclic nature of the utility interpersonal interactions where mutual need fulfilment following from psychological inherent aspects due to bonds two individuals together, but the intensity of the memory we now turn to the situation when the object need does not remain the same in time and of course the utilized/enjoyed is itself a subject. pleasure/satisfaction derived from the need-fulfilment interaction changes with repetition of fulfilment Subjectivity of the object cycles. Relationships may break when the utility turns Novel phenomena are expected to occur in sufficiently negative and crosses the threshold of any one of the partners. Huge complications often arise when one partner gets the threshold and the other is still in dire need of continuation.
Fig 4: Comparative marginal utilities of two subjects in a relationship
Figure 4 represents a typical situation where after The psychophysical interpretation of quantum several mutual need-fulfilling interactions over a period theory has been found useful in social sciences such of time, one partner reaches the threshold negative MU as sociology and political theory7. The process of while the other has not yet reached that point and still decision-making can be seen to be equivalent to the expects the relationship to continue in spite of both of process of wave function collapse in Quantum Physics8. them having had their peaks and subsequent decline in We explain here the consumer’s decision-making their MU. The first subject wants to break free because process as a quantum measurement process using the it is no longer pleasurable while the second subject still psychophysical interpretation. The alternative choices finds the first one to be of utility for its own needs and available put the psyche in a superposed state which, hence wants to continue with the relationship. Subjects upon decision, collapses to the definite alternative that are endowed with multiple needs and need-fulfilling is chosen. In the psychophysical interpretation, the capacities and hence have multivariate MU which backward travelling waves from future are interpreted can help sustain the relationship even if it fails in one to pertain to knowledge generation while the forward of the variables/capacities. Newer needs and newer moving physical waves correspond to information corresponding need-fulfilling capacities are often seen propagation. The pleasure-seeking consumer uses the to be resorted to by subjects in a relationship to ensure backwards waves from its future state in its interaction its continuation. Total failure of a relationship results with the good for buying that good from which the when there is a failure in each of the variables in the retarded waves complete the transaction. Whether the multivariate MU. consumer, having made that choice and possessing the good, actually gets the desired satisfaction or not in Consumer decision-making as a quantum future depends on the details of the myriad inevitable measurement process and psychophysical transactions that occur with that consumer and with that explanation 38 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
good every moment continuously till that point in future. Consciousness being what it is, can factor in this Ignoring the backward waves that carry information external influence and the informed and cautious about future pain, discontent and disappointment and consumer can always thwart such neuromarketing transacting only with those waves that carry information strategies. The commoner may of course be foxed for of pleasure, satisfaction and fulfilment, the non- some time by such neural activation but ultimately he too discriminating consumer falls into the hedonistic trap. will play safe. Like Biomedical sciences, Nuroeconomics It is the psyche that makes the decision and not the also interchanges the cause and the effect. In reality, it is brain. as if utilizing a free will in the matter of selecting the psyche that produces neural activity corresponding the pleasure-giving alternative (waves from future) to to decision-making and not the other way around. collapse by sending out more of pleasure-seeking waves Physical and physiological signals reaching the brain (figure-5).9 This is the inner psychophysical process of only stimulate the corresponding neural correlates, but decision-making by the psyche. Neural networks are the cognition, learning and decision-making are done by only utilized by the psyche to reach the decision and to the psyche using attention12. carry it out. Secondly, the initial bump notwithstanding, the MU does indeed diminish for any good whatsoever unless we are looking at cycles as discussed above. This will lead to production of less durable goods to ensure profit and it is already there. Thus neuroeconomics will ultimately fail.
Conclusion We have analyzed the hidden subjective aspects in the law of DMU and have brought to light several Fig 5: Psychophysical explanation of decision- issues that have been ignored on account of the love making: All Objects (goods) send out both pleasure- for objectivity and the conscious efforts to sweep aside signaling and pain-signaling offer waves from their the important psychological aspects that go into the possible future state of interaction with the subject, to which the subject (consumer) sends out only formulation of the law. There is an initial peak before pleasure-seeking retarded waves as confirmation the actual diminishing starts. There are cycles of need waves thereby completing the transaction. This and their fulfillment and according to the time interval, collapses the corresponding wave function for the there may be increase or decrease of the starting utility subject-object combine for their togetherness in and of the peak utility. The choice of a larger unit of the future and the decision is thereby made for that consumption hides the initial peak and gives the overall object. picture of diminishing of the MU. And finally, how Limitations of Neuroeconomics the mismatch of the diminishing of the MU in two subjects in case of interpersonal relationships may lead Neuroeconomics (consumer neuroscience or to complications such as breakups has been discussed. neuromarketing) promises to use neuroscientific The multivariate nature of the utility of a subject, the information to manipulate consumer behavior to possibility of adapting by developing newer utilities benefit the seller, thereby moving from exploration to (need-fulfilling abilities) is employed by subjects to exploitation, as happens with any science, whether it increase the MU thereby cementing relationships in concerns nature or human beings themselves. To what spite of the changing nature of the needs of the partner. extent which brain areas (fMRI and PET) are getting activated during decision-making (EEG and MEG) These findings can have implications for further corresponding to a stimulation is supposed to be the studies in psychology, sociology and even evolutionary guiding factor for influencing consumer choice10,11. biology. In particular, in the ultimate philosophy of Sensory signals apart, specific neural stimulation that is liberation of the soul from the phenomenal universe aimed at through such studies. of birth and death, it can also be understood as coming Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 39 about after several cycles of life and death, with the utility of income an investigation of its validity. MU of phenomenal existence diminishing in successive 1949. https://doi.org/10.1111/j.1467-6435.1949. incarnations till the aversion reaches the threshold tb00695.x negative value leading to renunciation as happened in 6. Marshall A. Principles of economics, Variorum the lives of Buddha and other liberated saints of self- edition, ed. Guillebaud C. Macmillan London. realization. 1961 7. Wendt A. Quantum Mind and Social science, CUP, Funding Statement: Self. Cambridge, UK. 2015 Conflicts of Interest: The authors declare no 8. Pradhan RK, Psychophysical Interpretation of conflict of interest. Quantum Theory. Neuroquantology.2012;10(4): 629-645. Ethical Clearance: Taken from the Head of the 9. Pradhan RK, Tripathy A. On the question of Institution for publication. freewill in a quantum physics inspired model of consciousness states, Neuroquantology 2019; 17(6 References ) :14-19 1. Gossen H. The Laws of Human Relations and 10. Lin H, Vartanian O. A Neuroeconomic the Rules of Human Action Derived Therefrom. Framework for Creative Cognition Perspectives on (Originally published 1854) Cambridge, MA: MIT Psychological Science, 2018;13(6):655-77. Press 1983. 11. Glimcher PW, Fehr E. Neuroeconomics – Decision 2. Kauder E. Genesis of the Marginal Utility Theory Making And The Brain 2nd Edition,Elsevier from Aristotle to the End of the Eighteenth Century. Academic Press, London. 2014, ISBN: 978-0-12- The Economic Journal. 1953;63(251):638–50. 374176-9 3. Ormanzabal KM. The Law of Diminishing 12. Pradhan RK, Tripathy A. Neural Recruitment Marginal Utility in Alfred Marshall’s Principles of in Subjective Time Perception in a Non-local Economics, The European Journal of the History of Model and the Psychological Nature of Attention, Economic Thought 1995; 2(1): 91-126 Neuroquantology, May 2019; 17(6):58-64. doi: 4. Dittmer T. Diminishing marginal utility in 10.14704/nq.2019.17.06.2392. economics textbooks. Journal of Economic Education, 2005;36 (4): 391-399. 5. Werner M. The law of diminishing marginal 40 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13828 Title of the Research article Assess the Awareness and Perception Regarding Birthing Process among Pregnant Women Residing in Tribal Areas of Bhandardara
Bharti Satish Weljale Associate Professor, Pravara Institute of Medical Sciences (Deemed To Be University), College of Nursing, Loni (Bk). Maharashtra
Abstract Background: Pregnancy and child birth is one of the greatest event in the life of a woman which she aspires and longs for with great expectation. She has fantasies about pregnancy and motherhood but when confronted with reality, many of them doubt their ability to cope with this great event.
A woman generally has notion that child birth is unbearable pain. This is formed as a result of the tales heard during adolescence or later in life. Child birth is a natural and universal phenomenon. Yet the knowledge of it among average women is haphazard, incomplete or distorted. So, researcher felt the need to assess the awareness and perception regarding birthing process among pregnant women.
Methods: Descriptive cross sectional research design was used with evaluative approach. Setting of the study was in tribal areas of Bhandardara. Samples were all pregnant women those who were available during study period. Sample size computed was total 100. Non probability convenient sampling technique was used for the study. Data was collected with help of dichotomous questionnaire on awareness and through interview their perception was assessed regarding birthing process.
Results: Percentage wise distribution of pregnant women according to their weeks of pregnancy in which majority (48%) were in 13-28 weeks of gestation, (36%) of pregnant women were grand multigravida. Majority (43%) of sample were of the age group of 19-21 years. The highest percentage (44%) of respondents had secondary education. Majority (37%) of samples were farming .The highest percentage (57%) of sample belonged to Hindu religion .The highest percentage (71%) of sample belonged to joint family The highest percentage (44%) of sample had a family income of 3001-5,000 rupees .Area wise Distribution of mean ,SD and mean percentage of awareness score regarding birthing process shows that overall mean knowledge score was (21.41± 9.25) which is 42.82% of max score indicate that pregnant women had poor level of awareness regarding birthing process. Pregnant women perceived that when there is an eclipse of the sun or solar, birthing process is very difficult to manage.
Conclusion: Findings of the present study concluded that the pregnant women had average knowledge regarding child birthing process. In this regard health personnel’s play a very important role as they have to educate the women about birthing process and have a healthier pregnancy.
Key terms: Awareness, Perception, Birthing process
Introduction and longs for with great expectation. She has fantasies about pregnancy and motherhood but when confronted Motherhood is a great responsibility & it is women’s with reality, many of them doubt their ability to cope highest crown of honor maintaining good health during with this great event.1 pregnancy. Pregnancy and child birth is one of the greatest event in the life of a woman which she aspires Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 41
The tribal population in India is 8-9% compared Setting of the study: Setting of the study was in with 72% in the selected district. In India 17% or nearly tribal areas of Bhandardara 50,000 of the 2.89 lakh women died as a result of Population: All pregnant women those residing in complication in pregnancy or childbearing in the year tribal areas of Bhandardara 2013.It is estimated that each year women suffer from pregnancy and its related complication and die annually Samples: All pregnant women those who were as a result of complication. Poor maternal health leads available during study period . to death and acute maternal mortality remains a major problem.2 Sample size: Sample size computed is total 100 was used. The WHO estimates that 287000 women died in 2010 due to the reason of pregnancy and its associated Sampling technique: Non probability convenient complication. In India maternal mortality ratio is 212 per sampling technique was used for the study. 1000,000 live births.3 Women in developing world suffer Criteria for selection of sample from short and long term morbidities which bought up by pregnancy and childbirth. It is major public health Inclusion criteria challenge in India. 4 A woman generally has notion that child birth is unbearable pain. This is formed as a result a) All pregnant women those who are willing to of the tales heard during adolescence or later in life. The participate in the study. information she gets from gossip, media or fiction draws b) All pregnant women who can understand Marathi a picture of passive pain to which a woman has to submit and Hindi in utter helplessness. A negative attitude during labor causes her entire body to tense up with fear and each Exclusion criteria contraction will become a signal of pain and therefore The pregnant women those who are not available will result in pain. Child birth is a natural and universal during data collection phenomenon. Yet the knowledge of it among average 5 women is haphazard, incomplete or distorted so, Data Collection Procedure researcher felt the need to assess the awareness regarding child birthing process among pregnant women. Ethical approval from the Institutional ethics committee of PIMS-DU, Loni (BK) was obtained Statement of problem: Assess the awareness and (Ref. No: PIMS/DR/CON/2019/307).Permission was perception regarding birthing process among pregnant obtained from Director, Centre for Social medicine, women residing in tribal areas of Bhandardara Loni(Bk). All participants was made comfortable and relaxed. Introduction of the investigator was given Objectives: to participants. Explanations regarding study and its 1. To assess the awareness and perception objectives was given to them. Before data collection regarding birthing process among pregnant women informed consent was obtained from study subjects. The investigator established good rapport with participants 2. To associate the awareness regarding birthing and assured confidentiality. Baseline data was assessed process with their selected demographic variables. and recorded. Awareness was assessed by interview method for 10-15 minutes and scored was given by Materials and Methods investigator. The perception was recorded as it is. At Research design and approach: Descriptive cross the end appreciation was given to participants by thanks. sectional research design was used with evaluative approach. 42 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Results Table No 1: Demographic description of samples by frequency and percentage N=100
SN Variables Category Frequency Percentage
1-12 10 10
1 Weeks of pregnancy 13-28 48 48
29-38 42 42
Primi 31 31
2 Gravida Multi 33 33
Grand multi 36 36
19-21 43 43
22-25 21 21 3 Age(in years) 26-29 20 20
≥30 16 16
Illiterate 9 9
Primary 18 18 4 Education Secondary 44 44
Higher secondary 24 24 5 Graduation and above 5
Housewife 24 24
Farming 37 37
Business 10 10 5 Occupation Service 6 6
Daily wage 20 20
Other 3 3 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 43
Cont... Title of the Research article
Hindu 57 57
Muslim 35 35 6 Religion Christian 5 5
Any other 3 3
Nuclear 8 8
7 Type of family Joint 71 71
Extended 21 21
<3000Rs. 20 20
3001-5000Rs. 44 44 8 Family income(per month) 5001-10,000 Rs. 26 26
>10,001Rs 10 10
Percentage wise distribution of pregnant women (5%) had graduation and above. Majority (37%) of according to their weeks of pregnancy in which majority samples were farming whereas the least percentage (3%) (48%) were in 13-28 weeks of gestation and remaining were other job. The highest percentage (57%) of sample (42% ) in 29-38 weeks of gestation.(36%) of pregnant belonged to Hindu religion and the lowest percentage women were grand multigravida followed by (33%) (3%) belonged to other religion. The highest percentage were multigravida. Majority (43%) of sample were of (71%) of sample belonged to joint family whereas the the age group of 19-21 years, whereas the lowest percentage (8%) belonged to nuclear family. The highest percentage (44%) of sample had a family income Least percentages (16%) were of the age group of of 3001-5,000 rupees and the lowest percentages (10%) ≥30 years. The highest percentage (44%) of respondents of sample had a family income of >10,001 rupees. had secondary education, whereas the lowest percentages
Table No 2: Frequency and Percentage Distribution of Sample according to awareness scores regarding birthing process N=100
Sr.no. Awareness level Range of score Frequency Percentage
1 Poor 0-8 12 12
2 Average 9-18 75 75
3 Good 19-25 13 13 44 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Pregnant women (75%) had average knowledge regarding child birthing process.
Table No 3: Area wise awareness regarding birthing process of Mean, SD and mean% of score N=100
Awareness score Area SN Max score Mean SD Mean%
1 Concept of birthing process 3 1.83 1.01 36.6
Onset of labor and normal physiology of 2 3 1.43 0.74 47.66 labor
3 Maternal nutrition in labour 3 2.53 0.87 63.25
Physical and psychological preparation 4 6 2.35 0.91 58.75 during birthing process
5 Management of labour 6 3.05 1.33 38.12
6 Recognition of complication 2 1.75 1.11 35
7 Initiation of Breast feeding 2 2.06 1.23 41.2
Overall 25 21.41 9.25 42.82
Area wise Distribution of mean ,SD and mean percentage of awareness score regarding birthing process shows that overall mean knowledge score was (21.41± 9.25) which is 42.82% of max score indicate that pregnant women had poor level of awareness regarding birthing process.
Table No 4: Perception regarding birthing process among pregnant women N=100
SN Variables Mean SD Mean% 1 When abdominal pain start, I need to sit on legs 19.48 4.651 67.17 2 No one support during labor 10.14 3.159 63.375 3 No diet and water is given during labour 4.02 1.039 67 4 Labor pain is difficult to manage 5.32 1.612 66.5 5 I have to lie on bed during birthing process 14.98 4.15 62.12 6 I feel anxious during labour 18.78 4.023 65.43 7 I need to listen staff while birthing process 10.14 3.159 63.375 8 I feel if I will eat papaya it will lead to miscarriage 6.23 1.45 62.21
Healthy diet will increase the weight of the baby and 9 8.54 1.98 61.11 staff will take me for caesarean When there is an eclipse of the sun or solar, birthing 10 19.43 4.78 65.34 process is very difficult to manage. Pregnant women perceived that when there is an eclipse of the sun or solar, birthing process is very difficult to manage as well as they perceived that when abdominal pain start, they need to sit on legs. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 45
Table No 5: Association between the awareness score with demographic variables N=100
SN Variables ᵡ2 Level of significance
1 Age 0.72 Not significant
2 Education 1.06 Not significant
3 Occupation 1.63 Not significant
(Df- 1, chi square value-3.84,p=0.05)
Chi square value was calculated to find out the knowledge regarding normal labour process. 4% of the association between the awareness with demographic primi mothers have good knowledge regarding normal variables. The finding reveals that there is no significant labour process. association between the awareness score regarding birthing process with their selected demographic Conclusion variables, hence the null hypotheses (H02) were Findings of the present study concluded that the accepted as there was no significant association between pregnant women had average knowledge regarding awareness with their selected socio demographic child birthing process. In this regard health personnel’s variables. play a very important role as they have to educate the women about child birthing process and have a healthier Discussion pregnancy. The world health organization recommends that healthcare providers should not admix in restriction of Source of Funding: Self low-risk women for eating and drinking during labor Conflict of Interest: None 6.The participants’ believed that the promotion of comfort was an essential need for them during labor. Intervening References to promote the comfort of laboring women can empower 1. JACOB A(2005) ‘a comphrensive textbook of these women during childbirth. Increasing comfort can midwifery 1st edition jaypee publishers new Delhi decrease labor pain, need for medical interventions and 2. Ministry of Tribal affairs.Scheduled Tribes in costs 7. She believed that women who indicate greater India: as revealed in the 2011 census.New Delhi: confidence in their strength to confront with labor also Government of India:2011[7 October 2013] express feeling less pain during labor 8, 9, and 10. She also 3. Mutreja S,Kumar A, Knowledge and practice of finds that women with low self-efficacy experience more birth preparedness among tribal women in sukman; fear of childbirth as well as fear of losing control during IOSR Journal of humanities and social sciences; labor 11also, results of childbirth investigation showed Publish on march 2015;Volume 20;Issue 3;Page that the self-efficacy influenced women. According to no 66-71 Available on www.iosrjournals.orgDOI: current study majority 75% of pregnant women had 10.9790/0837-20316671. average knowledge regarding child birthing process. 4. Malata A,Chirwa E, childbirth information feeds This finding was consistent with study carried out by to first time Malawian mothers who attended Rahul Punjot, Nitin Patidar, Naorem Jiteswori Devi et antenatal clinics; Malawi medical journal; publish 12 al(2018) that in their study majority 74% of primi June 2011; Issue 23(2); Pg no 42-46 mothers have average knowledge regarding the normal 5. WHO, UNICEF, UNFPA, World Bank Group and labour process.22% of the primi mothers have poor the United Nations Population Division Trends in 46 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
maternal mortality: 1990 to 2010 Estimates by importance of maternal confidence. Research in Publication: November 2012; Nursing & Health. 1989 Aug 1; 12(4):237-45. [24] 6. Sharts-Hopko NC. Oral intake during labor: a 10. Crowe K, Baeyer C. Predictors of a positive review of the evidence. MCN: The American childbirth experience. Birth. 1989 Jun 1; 16(2):59- Journal of Maternal/Child Nursing. 2010 Jul 1; 63. 35(4):197-203. 11. Lowe NK. Self-efficacy for labor and childbirth 7. Schuiling KD, Sampselle CM. Comfort in labor fears in nulliparous pregnant women. Journal of and midwifery art. Journal of nursing scholarship. Psychosomatic Obstetrics & Gynecology. 2000 Jan 1999 Mar 1; 31(1):77-81. 1; 21(4):219-24. 8. LOWE NK. Parity and pain during parturition. 12. Rahul Punjot, Nitin Patidar, Naorem Jiteswori Journal of Obstetric, Gynecologic, & Neonatal Devi et al., A Study to assess knowledge regarding Nursing. 1987 Sep 1; 16(5):340-6. [23] the process of normal labor among primigravida 9. Lowe NK. Explaining the pain of active labor: the mothers in selected hospitals of Pune city. Inno J Nur Health 2018; 4(2): 66-71. DOI Number: 10.37506/ijphrd.v12i1.13829 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 47 COVID-19 Essentials: Preparing Health Care Professionals before the Pandemic Spread in Kerala, India
Chithra Valsan,1 Ronnie Thomas,2 Joshi Paul Chirayath3, Varghese P R4, Praveenlal Kuttichira5 1Professor of Microbiology, 2Assistant Professor of Community Medicine & Epidemiologist, 3General Manager, HR, 4Research Coordinator, Jubilee Centre for Medical Research,5Principal, Jubilee Mission Medical College & Research Institute, Thrissur, Kerala, India
Abstract Background: In Kerala, an Indian State, COVID-19 treatment was restricted to government hospitals till the first week of August 2020. There was a suggestion to involve private hospitals if the disease spreads fast and wide. Three quarters of the healthcare delivery in the state is by private health care providers.
Methods: The hospital administration decided to train different levels of health care workers (HCW) in caring COVID-19 patients along with measures to remain safe from the disease. This was a mandatory two hours online training session covering the necessary topics as per the Guidelines of World Health Organisation (WHO) and Indian Council of Medical Research (ICMR). Post test was conducted based on the knowledge acquired during the programme, general awareness as a medical professional and media reports that a medical personal should follow.
Conclusion: The response from doctors was 73.7% (out of 559).More response was from the interns (96.4%). All the respondents appeared for the post test and 93.4% secured marks above the cut off level of 75%. The participation and high percentage of success rate shows the interest of medical professionals to step up their skill, especially when they face a new challenge.
Keywords: COVID 19 essentials, health-care preparedness, Continuing Professional Development programs, public health approach on COVID 19.
Introduction America (USA) over 1,000 health workers died of this pandemic disease by the end of August.3 An earlier The Corona Virus Disease of 2019 (COVID-19) report from China by the middle of February showed and its impacts confronts all with unpredictable, that 1,716 health workers were infected and six died disruptive situations which have changed daily lives, of this disease.4 In India 87,000 health workers were economies, political decisions and healthcare system. infected with COVID 19 and 573 died by August 2020.5 The healthcare workers are in the forefront of the battle Under these circumstances the safety of health-care to treat the patients as well to prevent the transmission, workers must be ensured. Health-care workers, unlike putting themselves at high risk. WHO says that 10% ventilators or wards, cannot be urgently manufactured global infections accounts for health workers.1 Amnesty or run at 100% occupancy for long periods. To boost analysis reveals over 7,000 health workers have died them to tackle the situation most judiciously is the need from COVID 19 by August.2 In United States of of the hour.
6 th Corresponding author: Since the first case reported from India on 30 Praveenlal Kuttichira January 2020, the country has reported over 50 lakhs E mail: [email protected] patients and 75,000 deaths by the end of August 2020. In the state of Kerala treatment centres for COVID-19 48 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 were limited in Government hospitals. However, actual service starts. The purpose of this article is it was felt that if the disease progresses, private to share the findings in academic circles of similar sector hospitals would also have to be involved at settings through scientific literature. some stage. This was more so as the private sector contributes 75.8% of health care delivery in the state.7 Methodology Online training modules were prepared by HICC With legacy of poor man’s hospital and and Community Medicine Department, in a tertiary commitment to service with love, this hospital health care centre in Central Kerala, India. The content administration decided to train different levels of details and resource persons are given in table1. Health Care Workers (HCW) in caring COVID-19 The session was for 2 hours with 8 modules and patients along with taking measures to remain 9th module was post test (table 2) consisting of 24 safe from the disease. In the event of a surge in questions (Google-form). Seventy five percent was COVID-19 cases all the medical personnel have to the cut-off for successful completion. The program, be equipped with the current protocols, treatment named COVID-19 essentials was implemented and guidelines, testing methods and the arrangements monitored by Human-Resources (HR) department of made in their institution. Besides social distancing, the institution. hand washing and use of face masks broadly meant for general public, the need for training HCW in A formal invitation was sent to all faculty, Infection Prevention and Control (IPC) in health care residents and interns by the Director on April 9th setting are highlighted by World Health Organisation of 2020. The training materials were uploaded on 8 (WHO). YouTube and link was sent to each prospective participant by the department of Electronic Data A medical board was constituted in our hospital Processing (EDP). The classes could be attended as to lead the COVID-19 care related activities. As per convenience of the participant. However all were per their decision, training programs were started requested to undergo the program on or before 12th from first week of April, the early part of pandemic April. outbreak in the state. This was a mandatory online training session covering the necessary topics as A second set of emails were sent to the per the Guidelines of WHO and Indian Council of prospective participants again as a reminder as well Medical Research (ICMR). This was conducted by as with an extension of completion date as 14th April Hospital Infection Control Committee (HICC) as 2020. Third set of emails were also sent on 18th April COVID-19 preparedness. The training for doctors 2020 to the new house surgeons directing them to was online to ensure maximum reach maintaining complete the training and the post test at the earliest. social distancing and it included faculty, residents The response from the participants are tabulated and and interns. presented.
The experiences and outcome of the training for There was no pre-test as the purpose of the program doctors were evaluated and reported here. The results was enhancing the preparedness of HCWs in managing will form baseline to make further improvements of Covid-19 patients. Post test was done to measure the the program and to note the good practices when amount of knowledge transfer occurred. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 49
Table.1:COVID-19 Essentials – course contents
Duration Session Topic Resource person in Minutes
1 Introduction Director 1:15
2 Hospital preparedness Medical superintendent of Hospital 2:57
Department of Community Medicine and 3 Epidemiology of COVID 19 11:43 Epidemiology
Clinical features, management and 18:15 4 Department of General Medicine prophylaxis
5 Sample collection & Diagnosis Department of Microbiology 14:37
6 Infection prevention& Use of PPE Hospital Infection Control Committee 16:00
7 Blue print of Fever clinic Department of General Medicine 8:28
8 Triage at Hospital Casualty Department of Emergency Medicine 6:22
9 Post test Human Resource Department
Table 2 The salient features of the post test questions includes the following apart from the questions to assess the category of the respondents.
1 Which is a high risk contact, how tested, COVID 19 hotspots and period of quarantine to different categories. 2 Regarding antibody detection tests and confirmation in the diagnosis of Covid-19 3 Category B symptoms, testing strategy for category B and C cases. 4 The proposed location for fever clinic in the institution, the mainstay of diagnosis in Covid19.Some puzzles like the following to comment 5 The red flag signs in a child suspected of covid-19 6 A young patient with acute respiratory infection symptoms, radiographic features of viral pneumonia and complete blood count showing leucopenia should be tested for COVID 19? 7 A 29 year old male with c/o mild sore throat and history of travel from Bengaluru ( a city from other state) five days back came to Emergency Department, what to do the patient 8. General question of helpline numbers and COVID related websites.
Results the post test and 93.4% secured marks above the cut off There were 559 doctors eligible to participate. level of 75%. Those who scored above cut off level were Among them 412 (73.7%) responded (Table 3). More 96.8% among interns, 91% among faculty and 89.1% response was from the interns (96.4%). In the category among residents. of ‘other doctors’ the response was hundred percentage, but was a small group. All the respondents appeared for 50 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3: Responses of doctors according to their categories
Faculty* Residents** Interns Other*** JR, PGs & Doctors Particulars SR & above House Surgeons Total Fellows
N (%) N (%) N (%) N (%)
Total number in the category 216(38.6) 135(24.2) 195(34.9) 13 (2.3) 559
Number of mails sent 216(100) 135(100) 195(100) 13(100) 559
Number of respondents who 139(64.4) 83(61.5) 188(96.4) 2(15.4) 412 participated
Number of respondents who 139(100) 83(100) 188(100) 2(100) 412 participated in post test
Number of respondents who scored 127(91.4) 74(89.2) 182(96.8) 2(100) 385 above cut off mark in post test
*SR & Above- Senior Residents, Asst Professors, Reports appearing in mass media and scientific Associate Professors and Professors journals as well as those in social media alerted the community of medical professionals about the possible **JR, PGs & Fellows- Junior Residents, Post wide spread of an unusual virus hitherto unknown.10,11 Graduate Medical Students and fellowship candidates in There was a Nipah outbreak in hilly terrain of Kerala specialty departments. in 2018.12,13 The experience gained was handy in *** Doctors serving legal services, quality assurance making preparations with public health approach based and charity on scientific epidemiological methods of intervention like contact tracing and containment for countering Considering the relatively small number in COVID-19 spread. categories and content of the classes were interlinked, item wise calculation of responses was not attempted. Our hospital used to be in the forefront of managing people in distress beyond the hospital premises at the Discussion time of crisis. Part of response to the impending spread of illness, we in our centre made preparations addressing Preparedness planning is essential in order to several issues. Starting fever clinic, setting triage to respond effectively during outbreaks and epidemics. screen cases suspecting COVID-19, risk assessment of Health-care workers who are at the frontlines in such everyone registering for OP consultation based on travel pandemics are the most vulnerable. Extra measures history and locality of living, preparing a standalone may be needed for health-care preparedness, to reduce treatment area for caring diagnosed cases in isolation, morbidity and mortality. WHO and Indian Council starting testing facility etc were a few steps. of Medical Research have published protocols and WHO offers online programmes for empowering the We had an outreach program where free general 8,9 healthcare professionals. At the time of our program, medical checkup and distribution of needed medicines no published reports of similar studies were available were arranged in the camps, where migrant workers from south Indian states. were living. A base line evaluation of the willingness Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 51
and emotional preparedness of staff in caring COVID-19 with challenges. The results will form baseline to make was conducted in the hospital. The HICC of our further improvements of the program and to note the institution is experienced in conducting such programs good practices when actual service starts. with noticeable positive results.14 Acknowledgement: We wish to acknowledge the The Medical professionals are aware about their management, departments of HR and EDP, and the training needs and they themselves take care of it. participants of this study at Jubilee Mission Medical Continuing Professional Development programs (CPD) College & Research Institute, Thrissur Kerala. is important for doctors15 through their wide network Ethical Clearance- We conducted the research reaching out even to small towns in the Country.16 Our following the Declaration of Helsinki. Hence ethical Institution appreciated this fact and organised a CPD approval was not sought. with theme COVID-19 essentials. The large number of responders from eligible staff in the institution point Source of Funding- Self to the willingness of professionals and endorses our assumption. The program through online mode was Conflict of Interest - Nil not a hindering factor. The same was our experience when we shifted our mode of teaching medical References students using online platforms8,17 temporarily due to 1. www.dw.com/en/coronavirus-latest-who- COVID-19 related lock down leading to sudden closure says-health-workers-account-for-10-of-global- of the college.18 The higher level of participation and infections/a-54208221, Accessed on: 19.09.2020 high percentage of success rate shows the keenness of 2. Amnesty.org. 2020. New Amnesty Analysis 7000 medical professionals in acquiring further knowledge Health Workers Have Died From COVID-19. and step up skill, especially when a new disease emerges Available at: https://www.amnesty.org/en/latest/ with challenges. news/2020/09/amnesty-analysis-7000-health- workers-have-died-from-covid19/ [Accessed 19 This training was attended by doctors belonging to September 2020]. various categories. The overall high rate of responses 3. Renwick, D., 2020. Over 1,000 US Health Workers and results are certainly a good sign from the part Died Of Covid-19. Many Were Immigrants And of doctors expressing their readiness to fight against Minorities. the Guardian. Available at: https:// this pandemic.There are reports on the relatively good www.theguardian.com/us-news/2020/aug/26/ commitment of medical staff to the preventive measures us-health-workers-covid-19-deaths-lost-on-the- that have been recommended by the WHO.19 The frontline [Accessed 19 September 2020]. variations between different categories were small 4. ETHealthworld.com. 2020. China Says 1,716 and negligible. Residents were the category who Health Workers Infected By Coronavirus, Six responded comparatively less in number (and in the Dead - ET Healthworld. Available at: https:// pass rate). They were the most occupied doctors in health.economictimes.indiatimes.com/ news/ the campus. Most of them were well versed to the new industry/china-says-1716-health-workers-infected- generation communication gadgets and may have felt by-coronavirus-six-dead/74143942 [Accessed 19 that these were familiar to them. In comparison to the September 2020]. residents the response from faculty was appreciable. 5. COVID-19, I., 2020. India: 87K Health Workers As the frontline warriors their response rate should Infected With COVID-19 - Pratidin Time. Pratidin be higher. Time. Available at: https://www.pratidintime.com/ india-87k-health-workers-infected-with-covid-19/ Conclusion [Accessed 19 September 2020]. 6. Andrews MA, Areekal B, Rajesh KR, Krishnan J, The higher level of participation and high Suryakala R, Krishnan B, Muraly CP, Santhosh percentage of success rate shows the keenness of PV. First confirmed case of COVID-19 infection medical professionals in acquiring further knowledge in India: A case report. Indian Journal of Medical and step up skill, especially when a new disease emerges 52 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Research. 2020 May 1;151(5):490-492 [online] Available at: https://www.who.int/ 7. Nabae K. The health care system in Kerala: southeastasia/outbreaks-and-emergencies/ its past accomplishments and new challenges. health-emergency-information-risk-assessment/ Journal of the National Institute of Public Health. surveillance-and-risk-assessment/nipah-virus- 2003;52(2):140-5. outbreak-in-kerala [Accessed 15 September 2020]. 8. Who.int. 2020. Critical Preparedness, Readiness 14. Valsan C, Paul J, Kuttichira P, Varghese R, Joseph and Response Actions For COVID-19. Available at: S. Economic Impact of Needle Sticks Injuries – A https://www.who.int/publications/i/item/critical- Retrospective Study from A Tertiary Care Hospital. preparedness-readiness-and-response-actions-for- Kerala Medical Journal. 2018 Sep 27; 11(3):60–5. covid-19 [Accessed 18 September 2020]. 15. Anshu, Singh T. Continuing professional 9. Mohfw.gov.in. 2020. Available at: development of doctors. The National Medical https://www.mohfw.gov.in/pdf/ Journal of India 2017;30(2):89-92. TrainingresourcesforCOVID1930MARCH.pdf 16. Srivastava V, Sullivan L, Sanghvi S. CME/CPD in [Accessed 18 September 2020]. the Indian Subcontinent: proceedings from the 1st 10. World Health Organization. 2020. Pneumonia Of regional meeting of Global Alliance for Medical Unknown Cause – China. Available at: https://www. Education (GAME) in Mumbai, India. Journal of who.int/csr/don/05-january-2020-pneumonia-of- European CME. 2015 Jan 1;4(1):27499. unkown-cause-china/en/ [Accessed 15 September 17. Rafi Mohammed, Varghese P R, Kuttichira. COVID 2020]. 19 Pandemic- Affidavit by academic personnel on 11. Helen Branswell, S., 2020. Cause Of well being and social responsibility from a Medical Wuhan&Rsquo;S Mysterious Pneumonia College in Central Kerala. Journal of the Social Cases Still Unknown, Chinese Officials Say. Sciences. July 2020; 48(3): 427-430. Scientific American. Available at: https://www. 18. Rafi AM, Varghese PR, Kuttichira P. The scientificamerican.com/article/cause-of-wuhans- Pedagogical Shift During COVID 19 Pandemic: mysterious-pneumonia-cases-still-unknown- Online Medical Education, Barriers and Perceptions chinese-officials-say/ [Accessed 18 September in Central Kerala. Journal of Medical Education 2020]. and Curricular Development. January 2020. 12. Arunkumar G, Chandni R, Mourya DT, Singh SK, doi:10.1177/2382120520951795 Sadanandan R, Sudan P, Bhargava B. Outbreak 19. Hessenow R, Hesenow S, Mohammad Y, investigation of Nipah virus disease in Kerala, India, Hammadyeh AR, Ghattas K, Ali L. Evaluation of 2018. The Journal of infectious diseases.2019 May preventive procedures followed by the medical 24;219(12):1867-78. https://doi.org/10.1093/ staff against covid-19 in the Syrian Arab Republic: infdis/jiy 612 A cross-sectional study. Indian Journal of Medical 13. Who.int. 2020. Nipah Virus Outbreak In Kerala. Sciences. 2020 Aug 21;72(2):49-57. DOI Number: 10.37506/ijphrd.v12i1.13830 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 53 Study on the Prevalence of Tuberculosis in HIV Seropositive patients attending the ART Centre, KIMS, Hubli
Dattatraya D Bant1, Raghavendra D2 1Professor and Head, 2Post-Graduate, Department of Community Medicine, Karnataka Institute of Medical Sciences, Hubballi, Karnataka
Abstract Background: The incidence of Tuberculosis (TB) has seen a significant rise in association with Human Immunodeficiency Virus (HIV) infection worldwide, in the recent years. It is evident that immunosuppression due to the HIV infection has resulted in modification of the clinical presentation of TB, thereby presenting with atypical signs and symptoms, and also sometimes affecting extra-pulmonary sites.
Objectives: To determine the pattern of presentation and prevalence of TB in HIV Seropositive patients and to study various socio-demographic factors associated with the same seen in the patients attending the Anti- Retroviral Therapy (ART) Centre, Karnataka Institute of Medical Sciences (KIMS), Hubli.
Methods: A cross-sectional study was conducted among 109 HIV Seropositive patients attending ART Centre in KIMS, Hubli, for a period of 2 months. A pretested, semi-structured questionnaire was applied to collect the data from the study participants after obtaining the verbal informed consent.
Results: The prevalence of HIV-TB among the study participants was estimated to be around 34.9%. Although HIV infection was found to be more in females in the study, TB with HIV infection was seen majorly in males. The commonly affected age group was 31-40 years, both in HIV infection alone and TB co-existing with HIV. Pulmonary TB was the commonest type of TB i.e., 92.1% among the HIV patients of the study. The prevalence of TB was found to be maximum in the cases with CD4 count of range less than 250 cells/cu.mm.
Conclusion: The prevalence of TB in HIV Seropositive patients was more than one third as per the study and hence it is of utmost concern that HIV patients should be screened and treated for TB as early as possible, and the prophylaxis of TB in HIV patients must be considered.
Key Words: Prevalence, Tuberculosis (TB), Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Disease Syndrome (AIDS)
Introduction throughout the world and is likely to endure and persist well into the 21st century. HIV infection has evolved Recognized as an emerging disease only in the from a mysterious illness to a global pandemic which early 1980s, HIV infection has rapidly established itself has infected tens of millions in less than 20 years.
Corresponding author: According to the recent estimates by the WHO Dr Raghavendra D and Joint United Nations Programme on HIV/AIDS Department of Community Medicine, (UNAIDS), nearly 36.7 million people were living with Karnataka Institute of Medical Sciences, HIV/AIDS worldwide, up from 28.9 million in 2001.1,2 Hubballi, Karnataka Globally, TB remains the most common cause of death Phone (or Mobile) No.: +91-8050290324 among patients with HIV/AIDS, killing 1 of 3 patients.3 Email: [email protected] 54 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
As per estimates, about 2.1 million people were Seropositive cases attending ART Centre of Karnataka living with HIV infection in the year 2015, in India, Institute of Medical Sciences, Hubli. with around 86,300 new HIV infections.4 About half of Before approaching the patients, permission was them are co-infected with Mycobacterium Tuberculosis; taken from the Medical Officer of ART Centre at KIMS thereby gradually develop active TB in association with Hubli. A convenient sample size of total 109 subjects HIV infection.5 were included in the study. The patients who are aged Available evidence on prevalence of HIV infection above 18 years and confirmed to be HIV Seropositive and future statistical projections shows signs of through necessary investigation reports were considered stabilization of HIV epidemic in India at national level. for the study. CD4 count of the patients were also However, one thing must be remembered in case of HIV- obtained from the records. TB, as both these diseases are a deadly combination; The data was collected by personal interview of they are far more destructive together than either disease the participants with verbal informed consent after alone. HIV infection is the strongest of all known risk explaining in their own language (Kannada, Hindi, and factors for development of TB. An individual who is HIV English). The confidentiality of the details of the patients Seropositive has 10 times increased risk of developing were maintained throughout the study. Those who were TB compared to an HIV Seronegative person.5 reluctant to participate in the study or hesitant to share As a result of HIV/AIDS, incident rates of TB in the information were excluded from the study. A pre- certain countries have gone up by more than 6 percent tested, semi-structured questionnaire was used to collect per year, crippling the already overburdened health care the demographic information and other relevant details resources.5 HIV infection and TB are also intricately of the study participants. linked to malnutrition, unemployment, alcoholism, drug abuse, poverty and homelessness. The direct and Statistical Analysis indirect costs of illness due to TB and HIV infection are Data was entered in MS-Excel and analysed using enormous. It has a catastrophic impact on the economy SPSS-21 software. The results were expressed in in the developing world. Thus, co-infection with HIV frequencies and percentages in the tables and figures. and TB (HIV-TB) is not only a medical malady, but a Appropriate statistical tests were used wherever required. social and an economic disaster and is aptly described as the “cursed duet”. Results
Hence, this study was undertaken to determine and Among 109 study participants who were HIV to ascertain the prevalence of TB in HIV Seropositive Seropositive, majority were females i.e., about 59 patients and the pattern of presentation of TB in HIV (54.2%) and remaining 50 (45.8%) were males. infected patients seen at ART centre, KIMS Hubli. It The participants of the study ranged from the age of also added the details to the pool of local data on patients minimum 21 years to maximum 65 years. Majority of presenting with these dreaded diseases. them i.e., 40.4% belonged to the age group 31-40 years. In the study, about 45.8% of the patients fall into Socio- Methods Economic Status (SES) of middle class as per Modified BG Prasad Classification. Most of the study subjects A cross-sectional study was conducted for a period were married i.e., 56.9%, followed by widowers, and of 2 months, to study the prevalence of TB in HIV only a few were either separated or single. (Table 1) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 55
Table 1: Distribution of study participants based on their socio-demographic characters
Socio-demographic Characters Frequency Percentage
Male 50 45.8% Gender Female 59 54.2%
21-30 26 23.8%
31-40 44 40.4% Age Group 41-50 27 24.8% (in years) 51-60 7 6.4%
> 60 5 4.6%
Upper Class 0 0.0%
Upper Middle 27 24.8%
SES Middle 50 45.8%
Lower Middle 32 29.4%
Lower Class 0 0.0%
Married 62 56.9%
Widower 35 32.1% Marital Status Separated 8 7.3%
Single 4 3.7%
In the study, about 38 of the HIV Seropositive along with HIV infection. However, all these findings patients i.e., 34.9% of them were co-infected with TB were not statistically significant. The only finding which (Figure 1). On further analyses, the co-existence of TB was found to be statistically significant in the study was with HIV infection was found to be more in males, and locality of the study subjects, indicating that people common in the age group 31-40 years. Patients belonging from urban areas were more prone to develop both HIV to Hindu religion, who were married, and also unskilled infection and TB. (Table 2) by their occupation were more prevalent in having TB 56 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 2: Prevalence of Tuberculosis among HIV Seropositive patients with respect to their socio- demographic characters
Chi-square Socio-demographic Characters TB Present TB Absent p-value value
Male 20 (52.64%) 30 (42.25%) Gender 1.0737 0.30 Female 18 (47.36%) 41 (57.75%) 21-30 9 (23.69%) 17 (23.94%) 31-40 15 (39.47%) 29 (40.84%) Age Group 41-50 10 (26.32%) 17 (23.94%) 0.7518 0.94 (in years) 51-60 3 (7.89%) 4 (5.64%) > 60 1 (2.63%) 4 (5.64%) Hindu 32 (84.21%) 60 (84.51%) Religion 0.0017 0.97 Muslim 6 (15.79%) 11 (15.49%) Urban 27 (71.05%) 36 (50.71%) Locality 4.2018 <0.05 Rural 11 (28.95%) 35 (49.29%) Married 23 (60.53%) 39 (54.92%) Widower 8 (21.05%) 27 (38.02%) Marital Status 5.2688 0.07 Separated 5 (13.15%) 3 (4.23%) Single 2 (5.27%) 2 (2.83%) Unemployed 10 (26.32%) 23 (32.39%) Unskilled 11 (28.95%) 24 (33.81%) Occupation Semi-skilled 9 (23.69%) 17 (23.93%) 3.521 0.47 Skilled 4 (10.52%) 2 (2.83%) Semi-professional 4 (10.52%) 5 (7.04%) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 57
Among the total population studied, majority i.e., around 66.9% of them were having the count of CD4 cells less than 250 per cubic millimetre. Even this was same on considering the patients with both HIV infection and TB, thereby implying that HIV Seropositive patients with CD4 count less than 250 cells/cu.mm. are at higher risk in developing TB (Table 3). In the fi gure 2, it is observed that out of 38 patients who are having both HIV infection and TB, most had developed Pulmonary TB i.e., 35 of them. (Figure 2)
Table 3: Prevalence of Tuberculosis among HIV Seropositive patients with respect to the count of CD4 cells
CD4 cells Count TB Present TB Absent Chi-square value p-value (in cells/cu.mm)
0-250 28 (73.69%) 45 (63.38%)
251-500 5 (13.15%) 19 (26.75%) 3.9858 0.26 501-750 2 (5.27%) 5 (7.04%)
>751 3 (7.89%) 2 (2.83%)
58 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Discussion possible if it has already been developed.
In the current study, the prevalence of Tuberculosis Limitations in HIV Seropositive cases was estimated to be 34.9%. Although this is quite significant value, it is less compared · The sample size of the study was limited to only to previous other studies.6 One important observation 109 patients which should not be missed is that these patients might · Duration of study was short. have either had TB earlier or developed during the course of the HIV infection. The commonest type of · Study was conducted in only one ART Centre. TB found among the study subjects was pulmonary TB · Convenient sampling was done because of the accounting for 92.1% of cases, while extra-pulmonary time constraints. TB accounted for only 7.9% of cases. This relatively low prevalence of extra-pulmonary TB could be attributed to Recommendations the unavailability of required diagnostic facilities. · It is strongly recommended that a large scale As per the study, the most common age group of multicentre prospective study is to be done to see the patients both in case of HIV infection alone and co- real TB/HIV co-morbidity and the course of TB in HIV infection with HIV and TB was 31-40 years. This is infected cases. almost similar to the findings obtained from the study done by Affusim CC et al.7 In the study, majority of the · Better diagnostic facilities should be made HIV Seropositive patients were females. However, in available to reduce the morbidity and mortality owing to case of HIV Seropositive patients who also have been TB among HIV Seropositive patients. diagnosed with TB, males were leading in the proportion. · Prophylaxis of TB among HIV Seropositive This could be due to the fact that males are more exposed patients should be taken into consideration as this could to outer environment compared to females. significantly reduce the associated morbidity. This also The distribution of TB cases among HIV holds good with the public health point of view. Seropositive patients was found to be commoner in Acknowledgements: The authors would like to those who are residing in urban areas i.e., 71%. This is thank all the study participants for extending their help contrast to the study conducted by SK Jain et al where in smooth conduct of this study. the majority cases were from rural areas.8 This is more likely due to the limitation in catchment area of our Declaration study. The religion of the patients in the study who are infected with both HIV and TB was noted that majority Funding: None of them were Hindus. This matches with the findings Conflict of Interest: None declared from the report by Preetish et al.9 Ethical approval: Not required Conclusion References The results of this study provide the information regarding the high risk of development of active TB in 1. UNAIDS (2016), AIDS by the numbers-2016 the persons infected with HIV. Such that more than one 2. UNAIDS (2016), Factsheet 2016, Global third of the study participants who had been diagnosed statistics-2015 as HIV Seropositive were found to be co-infected with 3. Sharma SK, Mohan A, Kadhiravan T. HIV-TB co- TB also. In the developing countries, tuberculosis is the infection: Epidemiology, diagnosis & management. commonest opportunistic infection among patients with Indian J Med Res 2005;121:550-67 HIV/AIDS. This calls for important steps to be taken to 4. WHO (2015), Country factsheet, HIV/AIDS in prevent the TB infection among the HIV Seropositive India, Dec.2015 through proper measures, and to treat TB as soon as 5. S. Swaminathan, R. Ramachandran, G. Baskaran Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 59
et al. Risk of development of tuberculosis in in HIV-seropositive patients seen at Benin City, HIV-infected patients. Int J Tuberc Lung Dis Nigeria. ISRN Pulmonology 2012;12(4):1-6 2000;4(9):839-844 8. Jain SK, Aggarwal JK, Rajpal S, Baveja U. 6. WHO, Global tuberculosis control 2011, WHO, Prevalence of HIV infection among tuberculosis Geneva, Switzerland, 2011 patients in Delhi- A sentinel surveillance study. 7. Affusim CC, Kesieme E, Abah VO et al. The pattern Indian J Tuberc 2000;47(21):21-26 of presentation and prevalence of tuberculosis 9. Preetish S. Vaidyanathan, Singh S. TB-HIV coinfection in India. NTI Bulletin 2003;39(3):11- 18 60 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13831 Title of the Manuscript: Impact of COVID-19 Pandemic on Mental Health and Effects of a Sense of Verdict of Selected College Students in Nepal, Nigeria and India
Deepak Vishwakarma1, Rejoice Puthuchira Ravi2, Ebbie Thomas3 1Assistant Professor, Department of Public health, P.P. Savani University, Dhamdod, Kosamba, Surat, Gujarat State, India, 2Associate Professor, Parul Institute of Public Health, Parul University, Vadodara, Gujarat State, India, 3Statistician cum Tutor, Department of Community Medicine, NAMO Medical Education and Research Institute, Silvassa, Dadra and Nagar Haveli, India
Abstract Background: The COVID-19 pandemic has brought a negative impact on mental health among college students across the world. Mental health issues are the leading obstacle to academic success. Aim of the study was to assess the prevalence and impact of COVID-19 on mental health and effects of a sense of verdict of selected college students from Nepal, Nigeria and India.
Methods: Non-probability, snowball sampling technique was applied for data collection. A total of 696 responses were recorded from selected colleges from Nepal, Nigeria and India. Online survey-based platform was used to distribute the e-questionnaire to collect the information. Online survey was conducted from 15th to 30th June 2020.
Results: More than half of the respondents 390(56%) had experienced depression during lockdown period. Majority of respondents 45(75.0%) from Nigeria had undergone depression followed by Nepal 73(58.87%) and India 271(52.93%). Young respondents 194(38.6%) in the age group of 18-20 years had experienced mild depression.
Conclusion: The lockdown due to COVID-19 pandemic has been brought an extraordinary academic challenge to the students across the world. It is necessary to adapt holistic approach to develop interventions and preventive strategies to address the mental health of college students for their well being.
Key words: COVID-19, mental health, depression, college students and lockdown
Introduction fear, frustration and worry for oneself or dear ones, constraints on physical movement and public activities The COVID-19 pandemic has been significantly due to quarantine, and rapid and radical lifestyle changes influencing the life of each and all people across the across the world. WHO, together with partners, is world. It is known that the prevalence of pandemic providing guidance and advice during the COVID-19 creates new stressors including depression, anxiety, pandemic for health workers, managers of health facilities, people who are looking after children, older Corresponding Author : adults, students, people in isolation and members of the Dr Rejoice Puthuchira Ravi public more generally, to help us look after our mental Associate Professor, Parul Institute of Public health, health. Parul University, Limda.P.O, Waghodia Taluka, Vadodara -391760, Gujarat State, India The COVID-19 pandemic has brought a negative Email : [email protected], (M): 09544432620 impact on mental health among college students across the world. Mental health issues are the leading obstacle Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 61
to academic success. Mental illness can affect students’ Students enrolled in the different colleges in Nepal, motivation, concentration, and social interactions-crucial Nigeria and India was considered for the present research factors for students to succeed in higher education.[1] study. Students in the age group of 18-34 years were Many countries declared lockdown strategy throughout selected for the research study. The study was conducted their country to minimize the gravity of its spread and among students only those who had an understanding of enforced pronounced restrictions on public life into English language and internet facility and were willing effect on middle of the March, 2020, to ensure ‘social to participate in the study. distance’ through ‘home quarantine’ to curb the ‘spread’ Sampling technique of COVID-19. As a part of implementing this strategy, all education institutions were closed initially from The Non-probability, snowball sampling technique March 16 to March 31 and later extended to June 2020. was applied for data collection. An informed consent As of June 7, 2020, around 6.91 million people were form was attached to the e-questionnaire and each infected with the COVID-19, with a confirmed fatality of respondent agreed to participate in the Online survey [2] another 0.4 million worldwide. Hence, many countries after reading the consent form. The respondents were implemented a range of anti-epidemic measures, such asked to share the e-questionnaire with their friends using [3] as restricting travel for foreign nationals, closing their personal network such as Email and Facebook etc. down public spaces, and shutting down the entire transit A total of 696 responses were recorded from selected [4,5] system, to contain the transmission of the highly colleges from Nepal, Nigeria and India. contagious infections from human-to-human. Data source Depression, anxiety, fear and worry are normal responses to perceived or real threats, and at times when Students enrolled in different colleges in Nepal, we are faced with uncertainty or the unknown. So it is Nigeria and India were the target population for the study. normal and understandable that people are experiencing The Questionnaire encompasses Basic information, fear in the context of the COVID-19 pandemic. Faced Depression and related information. An online survey- with new realities of work from home, home-schooling based platform was used to distribute the e-questionnaire of children, and lack of physical contact with friends to collect the information from the students. The and colleagues, it is important that we look after our e-questionnaire was developed by means of Google mental as well as our physical health. It is well known Form. Students from selected colleges in Nepal, Nigeria that pandemics pose a threat to mental health.[6–8] and India were contacted and interviewed through Correspondingly, 2 recent reviews found a consistently different social media networks. The Online survey was negative impact of COVID-19 on mental health, with conducted from 15th to 30th June 2020. Data analysis 16–18% of participants showing symptoms of anxiety was carried out using excel. Categorical variables were and depression.[9,10] The first evidence indicates that presented as frequencies and percentages. women,[11,12] younger people,[13] and those with a poor sleep quality[11,13] are at an increased risk for mental Results health problems. The aim of the present study was to The present study was conducted an Online survey assess the prevalence and impact of COVID-19 on through Google Form to assess the prevalence and impact mental health and effects of a sense of verdict of selected of COVID-19 pandemic on Mental Health and effects of college students from India, Nepal and Nigeria during a sense of verdict of selected college students in Nepal, 60 days of lockdown period from 1st April to 31st May Nigeria and India. A total of 696 responses were recorded 2020. from selected colleges from Nepal, Nigeria and India. All the participants were between the age group of 18- Materials and Methods 34 years. The study shows [Figure 1] that overall more Study design than half of the respondents 390(56%) had experienced and 306(46%) had not experienced depression due to A web-based cross-sectional survey method was COVID-19 during 60 days of lockdown from 1st April applied for collecting the information from the students. 62 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
to 31st May 2020. It is quite noticeable that [Figure 2] had experienced. The result shows that 65(9.3%) majority of college students 45(75.0%) from Nigeria respondents couldn’t keep their concentration on study had undergone depression due to COVID-19 followed during lockdown period. by Nepal 73(58.87%) and India 271(52.93%). [Table 4] illustrates the extent of depression during [Table 1] describes the degree of depression COVID-19 among college students according to country among college students according to country wise. wise. Around 8(13.3%) of students from Nigeria had The result indicates that highest number of college undergone ‘Feeling and Hopelessness’ almost entire students had experienced depression from Nigeria. period of lockdown (46-60 days). Students from Moreover, 7(12.7%) of respondents had faced severe Nepal and Nigeria had undergone ‘Sleeping problems’ depression from same country too. One forth 31(25%) & 21(16.9%) & 10(16.7%) respectively. It is noticeable 15(25%) of the respondents had experienced depression that students 15(12.1%) from Nepal had faced problems moderately from Nepal and Nigeria respectively. It is of ‘Fatigue’ almost all days during lockdown period highly noticeable that less than half of the respondents followed by Nigeria 6(10.0%) and India 19(3.7%). Result 241(47.1%) from India had never been exposed reveals that students who reside in Nigeria 8(13.3%) depression during the period of COVID-19 pandemic had experienced more ‘Appetite problem’ during followed by Nepal 51(41.1%). entire lockdown period followed by Nepal 14(11.3%). It concludes that students from various countries had [Table 2] indicates the degree of depression among undergone mental health problems due to COVID-19 college students according to their age. It is clearly understood that 3(6.3%) of respondents in the age group [Table 5] shows that respondents 5(8.3%) from of 24-26 years had experienced severe depression during Nigeria had experienced almost all days ‘Negative the lockdown period. This table highlights another feeling by themselves’ during lockdown period. While point is that 239(47.6%) & 41(46.1%) of student in the looking at the ‘Concentration problems’ throughout age group of 18-20 and 21-23 years respectively had the lockdown period towards academic activities none minimal experience of depression throughout the was reported very high among students from Nepal lockdown period and also 194(38.6%) of respondents 25(20.2%) & Nigeria 12(20.0%) whereas this cases was in the age group of 18-20 years had experienced mild very low in India 28(5.5%). Result also indicates that depression during the lockdown period. ‘Feeling frustration’ during 2 months lockdown period was high among Nigerian students 7(11.7%) but in India [Table 3] reveals the extent of depression among it was only 8(1.6%). It conclude that students in Nigeria college students during COVID-19. Around 62(8.9%) and Nepal had experience more degree of depression of the respondents had experienced ‘Sleeping problem’ during the period of lockdown. almost all days followed by ‘Fatigue’ 40(5.7%). When look at the ‘Appetite problem’ 50(7.2%) of respondents
Figure 1: Prevalence of Depression among College Students
Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 63
Figure 2: Prevalence of Depression among College Students by Country wise
Table 1: Degree of Depression among College Students by Country wise
Degree of Depression
Country Total Mild Severe None-minimal (%) Moderately (%) (%) (%)
Nepal 51(41.1) 41(33.1) 31(25.0) 1(0.8) 124
Nigeria 15(25.0) 23(38.3) 15(25.0) 7(12.7) 60
India 241(47.1) 195(38.1) 74(14.5) 2(0.3) 512
Total 307 259 120 10 696
Table: 2 Degree of Depression among College Students according Age
Moderately severe Age None-minimal (%) Mild (%) Severe (%) Total (%)
18-20 239(47.6) 194(38.6) 68(13.6) 1(0.2) 502
21-23 41(46.1) 24(27.0) 19(21.3) 5(5.6) 89
24-26 10(20.8) 19(39.6) 16(33.3) 3(6.3) 48
27-29 8(24.2) 12(36.4) 12(36.4) 1(3.0) 33
30-34 9(37.5 ) 10(41.7 ) 5(20.8) 0 24
Total 307 259 120 10 696 64 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table: 3 Extent of depression among College Students during COVID-19 Extent of depression during 60 days of lockdown period from 1st April to 31st May (N= 696) Variables Not at all (%) < 30 days 30-45 days 46-60 days
Work Pleasure 127(18.2) 187(26.9) 115(16.5) 267(38.4)
Sleep problem 430(61.7) 147(21.1) 58(8.3) 62(8.9)
Fatigue 423(60.7) 186(26.7) 48(6.9) 40(5.7)
Appetite problem 459(65.9) 131(18.8) 57(8.2) 50(7.2)
Negative feeling of yourself 541(77.8) 110(15.8) 25(3.6) 20(2.9)
Concentration problem 434(62.3) 158(22.6) 40(5.7) 65(9.3)
Movement slow fidgety 555(79.8) 82(11.7) 34(4.9) 23(3.3)
Thoughts of hurting yourself 612(88) 51(7.3) 20(2.9) 13(1.9)
Table 4: Extent of depression among College Students during COVID-19 by Country
Variables & Extent of depression during 60 days of lockdown from 1st April to 31st May 2020 Total (N= Country Not at all < 30 days 30- 45 days 46- 60 days 696) Work Pleasure Nepal 41(33.1) 34(27.4) 25(20.2) 24(19.4) 124 Nigeria 17(28.3) 17(28.3) 4(6.7) 22(36.7) 60 India 69(13.5) 137(26.8) 86(16.8) 220(43.0) 512 Feeling and Hopelessness Nepal 8(65.3) 28(22.6) 9(7.3) 6(4.8) 124 Nigeria 28(46.7) 20(33.3) 4(6.7) 8(13.3) 60 India 311(60.7) 145(28.3) 44(8.6) 12(2.3) 512 Sleeping problem Nepal 59(47.6) 32(25.8) 12(9.7) 21(16.9) 124 Nigeria 28(46.7) 15(25.0) 7(11.7) 10(16.7) 60 India 344(67.2) 100(19.5) 39(7.6) 29(5.7) 512 Fatigue problem Nepal 62(50.0) 35(28.2) 12(9.7) 15(12.1) 124 Nigeria 16(26.7) 27(45.0) 11(18.3) 6(10.0) 60 India 346(67.6) 122(23.8) 25(4.9) 19(3.7) 512 Appetite problem Nepal 77(62.1) 18(14.5) 15(12.1) 14(11.3) 124 Nigeria 35(58.3) 14(23.3) 3(5.0) 8(13.3) 60 India 348(68.0) 97(18.9) 39(7.6) 28(5.5) 512 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 65
Table 5: Extent of depression during lockdown period according to Country Extent of depression during 60 days of lockdown from 1st April to 31st May 2020 Total (N= Variables & Country 696) Not at all <30 days 30-45 days 46-60 days
Negative feeling of yourself
Nepal 94(75.8) 18(14.5) 7(5.7) 5(4.0) 124
Nigeria 41(68.3) 11(18.3) 3(5.0) 5(8.3) 60
India 408(79.7) 79(15.4) 15(2.9) 10(2.0) 512
Concentration problem
Nepal 67(54.0) 24(19.4) 8(6.5) 25(20.2) 124
Nigeria 25(41.7) 19(31.7) 4(6.7) 12(20.0) 60
India 341(66.6) 115(22.5) 28(5.5) 28(5.5) 512
Movement slow fidgety
Nepal 94(75.8) 13(10.5) 11(8.9) 6(4.8) 124
Nigeria 34(56.7) 13(21.7) 4(6.7) 9(15.0) 60
India 429(83.8) 56(10.9) 19(3.7) 8(1.6) 512
Thoughts of hurting yourself
Nepal 103(83.1) 8(6.5) 5(4.0) 8(6.5) 124
Nigeria 47(78.3) 3(5.0) 7(11.7) 3(5.0) 60
India 464(90.6) 38(7.4) 8(1.6) 2(0.4) 512
Feeling Frustration
Nepal 68(54.9) 33(26.6) 17(13.7) 6(4.8) 124
Nigeria 25(41.7) 20(33.3) 8(13.3) 7(11.7) 60
India 304(59.4) 187(36.5) 13(2.5) 8(1.6) 512 66 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Discussion delays, economic effects of the pandemic, and impacts on daily life. Furthermore, among the many student Globally, the potential impact of the COVID-19 surveys administered worldwide, one survey by Young pandemic on student’s mental health especially towards Minds reported that 83% of young respondents agreed academic activities is of increasing concern. The that the pandemic worsened pre-existing mental health present study was conducted an Online survey through conditions, mainly due to school closures, loss of routine, Google Form to assess the prevalence and impact of and restricted social connections.[29] COVID-19 pandemic on Mental Health and effects of a sense of verdict of selected college students in Nepal, Many respondents found that COVID-19 pandemic Nigeria and India. The present study shows that 56% had made difficult to adjust to the new academic routine of the respondents had experienced depression during during lockdown period and disturbed their preparations lockdown period due to COVID-19. The ongoing of academic life. This is a testimony to the fact that the COVID-19 pandemic is creating a psycho-emotional present scenario has been relatively disruptive in terms chaotic situation as countries have been reporting a of emotional and psychological health of the respondents sharp rise of mental health problems, including anxiety, concerned and required adjustment on part of them to get depression, stress, sleep disorder as well as fear, among acquainted to new life during the period of lockdown. its citizens.[14-18] The present study results revealed a 56% prevalence of depressive symptoms during the COVID-19 outbreak The present study shows that majority of college among students. The anxiety and stress symptoms were students (75.0%) from Nigeria had undergone depression found to be present in 49.06% and 43.19% of premedical due to COVID-19 followed by Nepal (58.87%) and students, respectively which is much more than the global India (52.93%). Furthermore, with the exception of prevalence of anxiety which was 33.8% and anxiety was high-burnout categories, depression levels among most prevalent among medical students from the Middle students, reported in several recent studies,[19,20,21] have East and Asia.[30] The study revealed that COVID-19 varied between 29% and 38%, which may suggest an is creating psychological distress among students, as uptick in pandemic-related depressive symptoms among there are limitations due to lockdown students are forced college students similar to recent studies in China.[22,23] to stay home and hence they are unable to attend the Although our participants specifically mentioned several physical classes for preparation for the professional factors such as feelings of loneliness, powerlessness, life and hence the most common mode of preparation as well as financial and academic uncertainties, other was found to be self-study and online classes as of the outcomes that were perceived to be impacted by the lockdown students are going through a crisis situation COVID-19 pandemic may also act as contributors to and feeling lack of control on their academic lives due depressive thoughts and suicidal ideation. In particular, to lockdown. both difficulty concentrating and changes in sleeping [24,25,26] habits are associated with depression . Conclusion For college students, heightened levels of The lockdown due to COVID-19 pandemic has psychological distress and downstream negative academic brought an extraordinary academic challenge to consequences are prevalent under normal circumstances. the students across the world. The findings of the As a result of physical distancing measures implemented study emphasize the multiple factors contributing to in response to COVID-19, tertiary education institutions students’ distress during this lockdown period. There have shifted to an emergency online learning format, is much impact on their mental health remains due to which would be expected to further exacerbate academic lockdown and what has to be done to diminish their stressors for students.[27] One study has explored the negative effects. Priorities should be included the impact of COVID-19 on student education and well- disturbances to educational progress and approaches being.[28] Approximately 25% of their sample reported academic institutions have taken to reduce adverse experiencing anxiety symptoms, which were positively academic and mental health outcomes. New data may correlated with increased concerns about academic help to inform student-centered support programs and Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 67
diminish the long-term negative implications for student strategy work well? Socio-Ecological Practice education and mental health. Due to the long-lasting Research. 2020:1-6. pandemic situation such as lockdown and stay at home, 6. Mak IW, Chu CM, Pan PC, Yiu MG, Ho SC and COVID-19 pandemic has brought negative impacts on Chan VL. Risk factors for chronic post- traumatic higher education. It concludes that there is necessary stress disorder (PTSD) in SARS survivors. Gen to adapt holistic approach to develop interventions and Hosp Psychiatry. 2010:32(6): 590-8. preventive strategies to address the mental health of 7. Mak IW, Chu CM, Pan PC, Yiu MG and Chan VL. college students for their well being. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry. Acknowledgement: We thank Dr. Satish Birader 2009:31(4):318–26. (Registrar P.P.Savani University), Dr. Anish Sharma 8. Lung FW, Lu YC, Chang YY, Shu BC. Mental (Dean School of Science P.P.Savani University), Mrs. symptoms in different health professionals during Kinjal (Assistant Professor SON P.P.Savani University), the SARS attack: a follow-up study. Psychiatr Q. Bikas Thapa (Nepal), Aminu Ibrahim Abubakar 2009:80(2):107-16. (Nigeria), Anita Thapa (Nepal), Mahesh Bahadur 9. Rajkumar RP. COVID-19 and mental health: a (Nepal) and students & staffs from Parul University and review of the existing literature. Asian J Psychiatr. all the participants from other Colleges. 2020:52:102066. Conflict of Interest : Nil 10. Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: systematic review Source of Funding : Nil of the current evidence. Brain Behav Immun. 2020. Ethical Clearance: Institutional Ethical Committee 11. Liu N, Zhang F, Wei C, Jia Y, Shang Z, Sun L, (IEC) of Parul Institute of Public Health has approved et al. Prevalence and predictors of PTSS during the research entitled “Impact of COVID-19 pandemic COVID-19 outbreak in China hardest-hit areas: gender differences matter. Psychiatry Res. 2020 on Mental Health and effects of a sense of verdict of May:287:112921. selected college students in Nepal, Nigeria and India” for the research activity. 12. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and References associated factors during the initial stage of the 2019 coronavirus disease (COVID- 1. Unger K. Handbook on Supported Education: 19) epidemic among the general population in Providing Services for Students with Psychiatric China. Int J Environ Res Public Health. 2020: Disabilities. Charleston, SC: Book Surge Mar:17(5):1729. Publishing. 2007. 13. Huang Y, Zhao N. Mental health burden for the 2. Coronavirus disease (COVID-19): Situation public affected by the COVID-19 outbreak in report-138. Geneva, Switzerland: World Health China: who will be the high-risk group? Psychol Organization: 2020 Health Med. 2020 3. Zhai Y, Du X. Mental health care for international 14. Gritsenko V, Skugarevsky O, Konstantinov V, Chinese students affected by the Khamenka N, Marinova T, Reznik A, et al. COVID COVID-19 outbreak. The Lancet Psychiatry. 19 fear, stress, anxiety, and substance use among 2020:7(4):e22. Russian and Belarusian university students. 4. Ahmed MZ, Ahmed O, Aibao Z, Hanbin S, Siyu International Journal of Mental Health and L and Ahmad A. Epidemic of COVID- 19 in Addiction. 2020. China and associated psychological problems. 15. Ahorsu DK, Imani V, Lin C-Y, Timpka T, Asian Journal of Psychiatry. 2020:51:102092. Broström A, Updegraff JA, et al. Associations pmid:32315963 between fear of COVID-19, mental health, and 5. Chen L, Yuan X. China’s ongoing battle against the preventive behaviours across pregnant women coronavirus: Why did the lockdown and husbands: An actor-partner interdependence 68 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
modelling. International Journal of Mental Health medical students in Ireland. BMJ Open. 2019 May: and Addiction. 2020:1-15. 01:9(4):e023297. 16. Savitsky B, Findling Y, Ereli A, Hendel T. Anxiety 22. W Fang Z, Hou G, Han M, Xu X, Dong J, Zheng J. and coping strategies among nursing students The psychological impact of the during the covid-19 pandemic. Nurse Education in COVID-19 epidemic on college students in Practice. 2020:102809. China. Psychiatry Res. 2020 May: 287:112934. 17. Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, 23. Liu X, Liu J, Zhong X. Psychological state of college Kaushal V. Study of knowledge, attitude, anxiety students during COVID-19 epidemic. SSRN J.2020 & perceived mental healthcare need in Indian Mar 24. population during COVID- 24. Acharya L, Jin L, Collins W. College life is stressful 19 pandemic. Asian journal of psychiatry. today - emerging stressors and depressive symptoms 2020:51:102083. in college students. J Am Coll Health. 2018 Oct: 18. Xiao H, Zhang Y, Kong D, Li S, Yang N. Social 66(7):655-664. capital and sleep quality in individuals who self- 25. Martin JM. Stigma and student mental health in isolated for 14 days during the coronavirus disease higher education. Higher Education Res 2019 (COVID-19) outbreak Dev. 2010 Jun:29(3):259-274. in January 2020 in China. Med Sci Monit. 2020:26:e923921–e. 26. Heiligenstein E, Guenther G, Hsu K, Herman K. 19. Zeng Y, Wang G, Xie C, Hu X, Reinhardt JD. Depression and academic impairment in college Prevalence and correlates of depression, anxiety and students. J Am Coll Health. 1996 Sep:45(2):59-64. symptoms of stress in vocational college nursing 27. American College Health Association: National students from Sichuan, China: a cross-sectional College health assessment II: Reference group study. Psychol Health Med. 2019 Aug:24(7):798- executive summary spring. 2019. 811. 28. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, Zheng 20. Nahas ARMF, Elkalmi R, Al-Shami A, Elsayed T. J. The psychological impact of the COVID-19 Prevalence of depression among epidemic on college students in China. Psychiatry health sciences students: findings from a public Research. 2020:287 university in Malaysia. J Pharm Bioallied 29. Young Minds. Coronavirus: Impact on young Sci. 2019:11(2):170-175. people with mental health needs. 2020. 21. Fitzpatrick O, Biesma R, Conroy RM, McGarvey 30. Travis Tian-Ci QUEK, Wilson Wai-San Tam, Bach A. Prevalence and relationship between burnout X. Tran, Min Zhang, Zhisong Zhang, Cyrus Su- and depression in our future doctors: a cross- Hui Ho, et.al. The global prevalence of Anxiety sectional study in a cohort of preclinical and clinical among medical students: A meta-analysis. Int. J. Environ. Res. Public Health. 2019:16:27-35. DOI Number: 10.37506/ijphrd.v12i1.13832 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 69 COVID 19 Awareness and its Impact on Periodontal Practice among Dental Care Professionals in Southern States of India- A Cross Sectional Survey
Lakshmi Ramachandran1, Janani Karthikeyan1, Santo Grace Umesh1, Anupama Tadepalli2, Harinath Parthasarathy3, Dhayanand John Victor3 1Assistant Professor,2Associate Professor, 3Professor, SRM Dental College, Bharathi Salai, Ramapuram, Chennai
Abstract Background: COVID 19 pandemic has nevertheless gripped our nation with its unshackled spread, varied disease characterization posing a real threat to health care workers and a high risk to dental professionals necessitating the publishing of guidelines to help dentists continue to provide optimum health services with safety. This cross-sectional survey aims to assess the awareness of the disease, knowledge of infection control and impact of COVID-19 pandemic on periodontal practice. Methods: The survey was conducted among 250 participants. The study instrument was a structured questionnaire that was grouped into four sections, namely demographic characteristics; awareness of the COVID pandemic, employment of infection control measures in combating COVID-19 pandemic; and the impact of COVID on periodontal practice. Statistical analysis was carried out using SPSS software and the data was presented as percentages. Conclusion: A total of 206 responses were considered as complete submissions which included 71.1%from the red zone, 12.5 % from the orange zone and 16.4% from the green zone. In conclusion, our study revealed that periodontists from Southern states of India were well acquainted regarding the pandemic. It is recommended that dentists should update themselves with the changing norms and adhere to follow national and international guidelines.
Key Words: COVID 19 pandemic; dental care professionals; infection control; periodontists; survey
Introduction The term “corona” is derived from the latin word, crown denoting the spherical shape and surface projections The novel Corona virus disease COVID 19 emerged of these enveloped viruses. Coronaviruses are divided in the city of Wuhan, China in December 2019 and into four groups: alphacoronavirus and betacoronavirus henceforth, witnessed unrestrained spread across the which target the respiratory, gastrointestinal and globe.1 The Chinese Center for Disease Control and central nervous system of humans and mammals, while Prevention identified the pathogen responsible of gamma coronavirus and deltacoronavirus primarily this viral pneumonia to be novel coronavirus (2019- target the birds.5-8 2019-nCoV belongs to the family nCOV) whereas,2 the international Committee on Coronaviridae of the order Nidovirales, B-lineage of Taxonomy of Viruses (ICTV) named it as “SARSCoV- the Betacoronavirus genus which are considered to be 2” owing to the similarity in the genomic sequence of zoonotic and can be transmitted from animals to humans. this novel coronavirus with other beta-coronaviruses 3,4 such as SARS-CoV and MERS-CoV. World Health ACE2 (human angiotensin-converting enzyme 2) is Organization declared the novel viral pneumonia as a the host cell receptor mediating infection by both SARS- pandemic on March 11, 2020. CoV and SARSCoV-2.9 ACE2+ cells are demonstrated to be abundantly present throughout the respiratory Corresponding author: tract and epithelium of salivary gland ducts, hence act Dr Lakshmi Ramachandran as early targets of SARSCoV infection.10 Due to the SRM Dental College, Bharathi Salai high binding affinity of SARSCoV-2 with ACE-2 and Ramapuram, Chennai 600089 [email protected], 91 9884690298 evidence of surge in the number of cases along with 70 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
sustained human-to-human transmission, 2019-nCoV India currently the third worst affected nation in the virus is by far considered the most contagious among the world. As an effective step in controlling the ferociously other counterparts(SARS-CoV and MERS-CoV).11-13 spreading COVID-19 pandemic, it is essential to assess the awareness and existing knowledge gaps among the Incubation period of COVID ranges from 2 to Indian dentists and formulate best practice guidelines 14 days, with a mean of 5 or 6 days.14,15 14 days is against COVID-19 spread. Among the specialties of considered as the globally implemented duration for dentistry, Periodontics deals with procedures incurring medical observation and quarantine of potentially high aerosol production during ultrasonic scaling as well exposed persons.16,17 Around 80% of infected cases as involves prolonged exposure with patient’s oral fluids are asymptomatic carriers who may serve as potential and blood during surgeries. Hence, the present study reservoirs for infection transmission.18,19 Patients with was undertaken with the aim to assess the awareness of COVID-19 may present with an array of symptoms the disease, knowledge of infection control and impact ranging from fever, dry cough, myalgia, fatigue, nasal of COVID-19 pandemic on periodontal practice. congestion to other atypical symptoms such as nausea, diarrhoea, confusion, headache, hemoptysis, stomach Materials & Methods pain, dizziness, hyposmia and dysgeusia.20 The infection This observational cross-sectional study was designed can progress to cause severe respiratory distress with a following STROBE guidelines and was approved by fatality rate around 3 % in India. the ethical committee and institutional review board of Dental clinical settings invariably possess high SRM university (SRMU/M&HS/SRMDC/2020/S/020). risk for spread of 2019-nCoV infection due to the The study instrument was developed after reviewing unique nature of dental interventions which, involves pertinent literature, international and national face-to-face communication with patients, aerosol guidelines,27-30 and was distributed via google forms generation, handling of sharps, proximity of the dentist which is available at: https://docs.google.com/forms/ to the patient’s oropharyngeal region, frequent exposure d/e/1FAIpQLScEbYDtYqFOvV37c0AheAU1FSr6e to saliva, blood, and other body fluids. Infection mZTla5cU6BcvEGRj_FcMw/viewform?usp=sf_link. transmission in the dental offices can potentially The questionnaire was formulated in English and be carried out in one of these routes,21 (i) Airborne comprised of 37 questions based on the four categories transmission - Intrinsic nature of dental procedures such - demographic characteristics; their awareness of the as high-speed handpiece or ultrasonic instruments in COVID pandemic; employment of infection control infected patients make their secretions, saliva, or blood measures in combating COVID-19 pandemic; and the aerosolize to the surroundings.22 Virus- laden aerosols impact of COVID on periodontal practice. The questions are small enough to stay airborne for an extended period were mostly multiple choice or yes/no in nature with less before they settle on environmental surfaces or enter than three open ended questions. the respiratory tract through inhalation. (ii) Contact Study population consisted of subjects primarily transmission may be either through direct contact with practicing clinical periodontics i.e., individuals pursuing infected patient’s body fluids (blood, oral fluids), nasal/ master’s program in periodontology and also specialists oral mucosa loaded with droplets and aerosols containing who completed their master’s program in Periodontology microorganisms or indirect contact with dental apparatus &oral implantology. Clinicians specialized in other fields which get contaminated following treatment of infected of dentistry and general practitioners were excluded. individuals.23,24 (iii) Surface transmission through contaminated environmental surfaces like metal, glass This survey was conducted between 1st and 20th or plastic that are frequently contacted by dental care of June 2020. Convenience sampling methodology was 25,26 personals. employed and the questionnaire was distributed to 250 participants personally via e-mails as well as posted Life threatening COVID-19 infection is currently on various social media platforms like Facebook and impacting India in an unprecedented manner ever since WhatsApp (Figure 1). The dentists’ consent to participate its first case was reported on 30th January 2020, making in the study was inferred when they voluntarily agreed Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 71 to respond to the questionnaire. Among 250 participants, 44 were excluded owing to incomplete submissions and a total of 206 responses were recorded. Only the principal investigators had access to the data and no personal details (phone number, name, etc.) were required as a part of sample collection.
Figure 1 – Study design
Data were analyzed using SPSS (IBM SPSS Statistics Results for Windows, Version 26.0) with a significance level This study included a total of 206 (70.1%female of 5% (α = 0.05). Kruskal Wallis test was performed and 29.9% male) participants, forming a response rate of to compare values between zones, Bonferroni adjusted about 58.8% (206 out of 350 invited participants). The Mann Whitney test was used for multiple pairwise sociodemographic characteristics are shown in Table 1. comparison and Chi-Square test was applied to compare Out of 206 respondents,71.1% resided in the red zone proportions. Categorical data were described in terms of with majority of the population having 1 to 5 years of percentage. clinical experience (63.8%). Among the subjects,65.05% were periodontists and the remaining were pursuing 72 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Masters in Periodontics (34.95%).
Table 1 – socio-demographic data of the respondents
VARIABLE CHARACTERISTIC n(%)
21-30 48.1
31-40 36.5 Age group distribution(in years) 41-50 13.5
51 and above 1.9
Male 29.9 Gender Female 70.1
Red zone 71.1
Zone distribution Orange zone 12.5
Green zone 16.4
1-5 63.8
Years of clinical practice 5-10 11.2
Greater than 10 years 25
Mode of Practice Periodontist 65.05
Post Graduate 34.95
In Figure 2, the questions pertaining to the awareness 37.9% were aware of the types of reusable respirators of the pandemic were correlated with the years of (Filtering facepiece and Powdered air-purifying practice of the participants. All participants were aware respirators) with a fairly similar response of 38.9%, that every patient could be a potential asymptomatic 36.4% and 35% in the 1-5, 5-10 and > 10 years groups carrier of the disease.85.4% of respondents agreed respectively. Around 50% of the study population prefer that telephonic staging is a reliable approach which to adjust the facemask after performing hand hygiene, was statistically significant (p<0.05) with a unanimous however only 15.5% were aware of the recommended positive response from the 5-10 year group.95.1% of the guidelines of adjusting facemask both before and after participants were acquainted about all the precautions to performing hand hygiene and this question showed be followed at the reception desk.66.0% were displaying statistical significance (p<0.05). visual alerts in their clinic to educate patients, which was also statistically significant (p<0.05). Alarmingly only Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 73
Fig 2 - Response chart correlating years of practice with awareness of the periodontist
Table 2 depict the response chart comparing mode periodontists and 63.9% of post graduates considered of practice with employment of infection control 90 GSM of PPE and above to be ideal for reuse (Table strategies. 82.5% of the respondents believed in 3 B). Statistical signifi cance was exhibited among the designating separate areas for aerosol and non-aerosol responses favouring 1% povidone iodine as the most procedures with a nearly even distribution of responses effective preprocedural mouth rinse. However, the post from both the periodontists and the postgraduates. With graduates showed a preference to use 0.2% CHX (44.4%) regards to the type of ventilation that is contraindicated, in contrast to the periodontists who opted for povidone 37.3% of periodontists and 38.9% of postgraduates gave iodine (52.2%). In accordance to DCI guidelines, only the right response.85.4% of participants affi rmed that 33% of the study population abided to scrubbing with chemically treating the water reservoir reduces infection isopropyl alcohol prior to dental procedures. transmission. Statistical signifi cance was observed in the With respect to periodontal practice, the highest question on the most suitable method of operatory fl oor incidence of particle transmission is noted with disinfection with 83.6% of periodontists and 61.1% of ultrasonic/ sonic instrumentation and this response the postgraduates giving the right response (p<0.05). (66.7% of periodontists and 83.3% of post graduates) 96.1% of the respondents reported that disinfecting had statistical signifi cance (p<0.05). 73.8% of the dental chair in between every patient is necessary. respondents felt that treatment effi ciency may get reduced Around 70% of periodontists and postgraduates chose by hand instrumentation, if opted as an alternative to surface wiping with hospital grade disinfectants as ultrasonic scaling. the best mode of dental chair disinfection.76.9% of 74 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 2 Response chart comparing positive accurate responses between mode of practice with infection control & clinical practice
MODE OF PRACTICE p-value QUESTION Periodontist Postgraduates Overall
83.6% 80.6% 82.5% 0.585 Separate Clinical areas Type of ventilation contraindicated 37.3% 38.9% 37.9% 0.199
Chemical treatment of water reservoir 88.1% 80.6% 85.4% 0.145
Operatory floor disinfection 83.6% 61.1% 75.7% 0.001*
Frequency of disinfecting dental chair 97.0% 94.4% 96.1% 0.243
Best mode of disinfecting dental chair 71.6% 69.4% 70.9% 0.914
GSM of reusable PPE 76.9% 63.9% 72.3% 0.098
DCI recommendation prior to dental procedure 35.8% 27.8% 33.0% 0.266
Hand instrumentation reduces Treatment efficiency 70.1% 80.6% 73.8% 0.105
Highest incidence of particle transmission 66.7% 83.3% 71.9% 0.025
*- denotes statistical significance p<0.05
Figure 3 shows responses correlating the zone 93.2% considered pain associated with periodontal of clinical practice and impact of COVID-19 on abscess/ tooth mobility as the true periodontal periodontists. 5.9%, 15.4%, 23.3% of periodontists emergency that was statistically significant (p<0.05). residing in the green, orange and red zone respectively Moreover, 23.5%,38.5%,21.9% of the respondents from had difficulties in bio medical waste disposal. An the green, orange and red zone respectively had attended overall statistical significance (p<0.05) was noted in emergencies donning a PPE. 11.8%,7.7% and 9.6% the question regarding possession of fumigator (71.8%) of practitioners from the green, orange and red zone wherein, alarmingly only 20.5% of dentists from the respectively continued to perform aerosol generating red zone owned a fumigator. Across all zones, 90.3% procedures. However, 83.5% of the periodontists had of practitioners believed that OPG was the most ideal refrained themselves from performing non-emergency diagnostic radiograph amidst the pandemic contributed periodontal procedures. 58% of the periodontists by 97.3%, 69.2% and 76.5 % of red, orange and green specified that they did not practice periodontics during zone respondents respectively which was found to this period. However, 1% of the entire study population be statistically significant (p<0.05). 56.3% of the stated a good periodontal practice despite the pandemic participants preferred four handed dentistry. challenges (Figure 4). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 75
Figure 3 - Response chart correlating zone of practice and its impact on periodontists
Figure 4 - The impact of the pandemic on the overall periodontal practice 76 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Discussion with 5-10 years’ experience were in concordance.32
The rampant spread of SARSCoV-2 across the Indian Dental Association recommends posting nation has increased the likelihood that dental care visual alert icons on hand hygiene, respiratory hygiene, professionals may treat the subset of patient population and cough etiquette in the reception area to educate the harbouring the virus. In response to this challenging patients.33 With regards to the question on visual alerts, pandemic, the WHO, Center for Disease Control and positive response was noted from 90% of practitioners Prevention (CDC), American Dental association (ADA), with 5-10 years of experience suggesting that this group the National Health Service (NHS), as well as other were more updated with the current national guidelines. health regulatory bodies have instituted standardized, As the need for continuous respiratory protection arose professional guidelines to help regulate dental services with the uncertainty of SARSCoV-2 virus transmission and provide measures for prevention, identification and the fact that coronaviruses lose their viability and management for appropriate mitigation of further significantly after 72 hours 34, we assessed the knowledge spread of COVID-19 disease. Since SARSCoV-2 virus on reusable respirators. is abundantly present in saliva and nasopharyngeal secretions of patients once it gets into the body and reports Previous studies have evaluated the awareness of claiming almost 90% chances of infectivity are evident COVID 19 among dental students and practitioners, but for dentists among the health care providers, dental failed to differentiate the gap of knowledge between 35,36 professionals are at maximum risk for transmission and students and practitioners. The following section of contraction of nosocomial infection and can become the questionnaire dealt with infection control strategies potential carriers of the COVID-19 disease.31 All these comprising nine questions and their responses were facts can have serious implications in the routine dental compared with the mode of practice (Periodontists, practice and if adequate precautions are not taken, the Post graduates). 112 periodontists and 58 post graduates dental clinics and hospitals can potentially lead to cross were in confluence with performing aerosol generating contamination. procedures in separate negative pressure areas in the dental office, referred as Airborne Infection Isolation To evaluate the readiness among professionals Room (AIIR).30 In par with the CDC and DCI guidelines, to steer through this pandemic, the questionnaire questions on ventilation systems, floor disinfection and was targeted at their understanding of the disease pre procedural mouth rinse were framed. To our surprise, presentation, identification of patients with 2019-nCoV the results suggested that neither the periodontists nor infection, knowledge of infection control measures, the post graduates had a clear insight into the infection treatment modifications and adoption of other protective control strategies depicted by the mixed responses that measures. This also helps the dentists in early detection were received. This was in contrast to the previous of disease and upgradation of past preventive strategies study done among Indian undergraduate dental students if the COVID-19 reverberates into the future and the who showed adequate knowledge on the disease second wave of the disease transpires. origin, etiology, transmission, features, diagnosis and prevention.35 However, the guidelines provided To the best of our knowledge, this is the first study by the Indian government were not focused on their that evaluates the awareness of COVID-19 among questionnaire and that could be the reason for variation periodontists in South India. The section on awareness in the results. The study done in Mumbai showed that consisted of six questions and their responses were a higher percentage of correct responses were from compared with the years of professional practice. undergraduate medical students and the lowest was from According to national and international guidelines, non-clinical/administrative staff.36 telephonic staging of patients could be a safe method of grouping the patients according to their required level According to the Guidelines for the Diagnosis and of dental care into emergency, urgent and elective care, Treatment of Novel Coronavirus-Infected Pneumonia thereby prioritizing the dental services and reducing the published by the National Health Commission of the risk of cross infection, to which 100% of the practitioners People’s Republic of China, it was observed that the Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 77
most commonly used chlorhexidine mouth rinse, had no performing non-emergency periodontal procedures such effect against COVID-19. Instead, they suggested use as scaling, root planing and polishing in par with the of oxidative agents such as 1% hydrogen peroxide or guidelines. Hand instrumentation could be an alternative 0.2% povidone whereas,21 ADA and CDC considered to aerosol generating ultrasonic instrumentation but its hydrogen peroxide to be most superior.30,37 Another study efficiency is a concern and three fourth of the participants done among Turkish dentists suggested that although sided to the fact of efficiency being hampered. However, the practitioners had adequate protective measures, their if aerosol-generating procedure needs to be performed, attitude towards sustaining COVID preventions had not it should be scheduled as the last appointment of the reached sufficient levels .38 However, a multinational day and four-handed dentistry with high volume suction study showed that 79% dental practitioners followed for aerosols should be implemented along with regular the recommended preventive measures provided by the suction.44 government.39 At this hour of pandemic, dental professionals The last section of our study on impact on must be constantly aware of infectious threats that may periodontal practice consisted of eleven questions out of challenge the current infection control regimen, act which the responses of nine questions were compared diligently and understand the importance of organized with the zone of practice. The zones were categorized dental care provided with appropriate infection control as per the government of India into Red, Orange and measures such as personal protective equipment, Green zones. Majority of the respondents were from red detailed patient evaluation, handwashing, mouth rinsing zone due to progressive involvement of a large part of before dental procedures and disinfection of clinic.27,28 the population in the pandemic. The dental clinics in the red zone faced difficulties in biomedical waste disposal Conclusion owing to the stringent lockdown imposed. Despite In conclusion, our study revealed that periodontists guidelines advocating fumigation of dental operatory, from South India had adequate awareness regarding 79.5% of dentists in the red zone neglected the use of COVID 19 pandemic with a fairly moderate knowledge fumigators. This could be possibly attributed to their on infection control strategies, which can be further preference towards Ultraviolet-C irradiation lamps since enhanced by updating and conforming to the current it is a quicker option especially between patients and guidelines. On the other hand, periodontal practice was 40 rarely produces potentially dangerous by-products. undoubtedly affected and faced a drastic fall. In order Previous study suggested that across the globe, among to strike a balance between the safety of dental care dental practitioners, 46% felt safe to perform dental professionals and provision of optimum dental services, 41 procedures donning a PPE. Irrespective of the dentistry has to revolve itself. residing zones, majority of the respondents agreed over the usage of OPG owing to the drawbacks of IOPA Conflict of Interest – Nil such as stimulation of saliva secretion and induction of Source of Funding – Nil coughing.42
Pain associated with periodontal abscess and tooth References mobility was the most opted emergency that requires 1. Dong E, Du H, Gardner L. An interactive web- immediate dental care and one fourth of the participants based dashboard to track COVID-19 in real time. attended periodontal emergency donning a PPE. It is Lancet Infect Dis 2020; 20(5):533-534. recommended for periodontists and dental surgeons to 2. Qun L, Xuhua G, Peng W, Xiaoye W, Lei Z,Yeqing adhere to the use of highest level of personal protective T., et al. Early transmission dynamics in equipment (PPE) available which involves gloves, Wuhan, China, of novel coronavirus–infected gown, head cover, shoe cover, eye protection including pneumonia. N Engl J Med 2020; 382:1199-1207. goggles or a disposable/reusable face shield that covers 3. Zhu N, Zhang D, Wang W, et al. A novel coronavirus the front and sides of the face, and a N95 or higher level from patients with pneumonia in China, 2019. N respirator.43 Around 80% of the respondents deferred Engl J Med 2020;382:727–733. 78 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
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Manish A. Prasad1, Deepti Chandrakar2 1Associate Professor, Department of Community Medicine, Government Medical College, Ambikapur, Chhattisgarh, India, 2Master of Public Health, State Consultant NPPCD, Indravati Bhavan, Naya Raipur, Chhattisgarh, India,
Abstract Background: Quality of services, convenience of approach, lack of personal attention and long waiting time have been found to be significant barriers for seeking health care in public sector, which requires to be addressed. Objective: The present study was conducted with the objective to assess the health seeking behavior and general health problems among female patients visiting a health center in Ambikapur. Materials and Methods: A cross-sectional study was conducted among 101 patients visiting a rural health center in Ambikapur. Result: The present study clearly reveals there is a preference for government health facility among female patients in the rural area of Ambikapur. Conclusion: This government health facility was nearest as compared to other nearby government health facilities, it was affordable and a preferable choice for the rural patients due to trust on the doctors and staff.
Key words: Health care seeking behavior, Health care facility, Out Of Pocket Expenditure (OOPE), Transport, general health problems
Introduction The most important factor affecting respondents’ choice of healthcare provider, 34.5% of respondents Health status play very important role in the quality considered the good services provided by the provider [1] of life of an individual . Many health problems are as the most important reason for their patronage of such known to increase with age and this demographic trend provider. On the contrary, affordability was the second may lead to an increase in the absolute number of health least popular reason (6.8%) for selecting health provider [2] conditions in the population . among respondents who completed tertiary education [4] Health seeking behavior is lower in the slums . Quality of services, convenience of approach, lack compared to non-slum urban areas. Various studies from of personal attention and long waiting time have been developing countries have reported delay in seeking found to be significant barriers for seeking health care in [5] appropriate care [3]. public sector, which require to be addressed . Health seeking behavior is a dynamic process evolving through stages of self evaluation of symptoms, Corresponding author: self treatment, seeking advice from family and social Dr. Manish A. Prasad, networks and seeking advice from professional sector. Department of Community Medicine, It is a mix of various social, cultural, personal and Government Medical College, environmental factors [6]. Therefore the present study Ambikapur, C.G. Pin code: 497001 was planned in female patients to observe the common Email: [email protected] health problems among them and to study their health Mobile number: 09860690142 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 81 seeking behavior with the following objective to assess various health illnesses they were suffering from was the health seeking behavior and general health problems provided and appropriate referral was done. The data of female patients visiting a rural health center in thus collected was entered in the Ms. Excel sheet. It Ambikapur. was analyzed with the EPI info and SPSS 16.0 software. Results thus obtained were presented in the form of Materials and Methods frequency tables and logistic regression analysis was It is a cross-sectional study conducted among done to check the association of health seeking behavior patients visiting rural health centre in Ambikapur in with other variables and P value less than 0.05 was the month of January 2020. Female patients coming for considered as significant. treatment in a rural health centre in Ambikapur formed Results the study population. Inclusion criteria included the female patients aged 18 years and above, female patients Table 1 shows 88.11% female patients preferred coming to a selected rural health centre for treatment government health care centers and a few 11.88% also and all those who gave written consent to participate in visited private hospital for treatment. 47.52% utilized the study. The exclusion criteria were female below 18 own motor vehicle or public transportation to reach years age, those unable to respond to the questions and the health center. 32.67% took less than 15 minutes to those not willing to participate in the study. reach the health center and 51.48% required more than 30 minutes to reach the health center. 27.72% reached Sample size (N) = Z2 (p x q / l2), N= sample size, health center within 1 to 2 days of illness whereas p= prevalence based on previous study, q=1 – p, l = 35.64% took about 3 to 7 days after their illness to seek allowable error. Therefore considering prevalence health care. About 20.79% came after 1 month to the [7] of musculoskeletal pains 50% from the previous hospital after their illness. 80.19% patients did not have studies q=50 and allowable error to be 10% the sample to spend any amount of money while 19.80% had to size comes out to be 100 with a confidence level of spend some amount of money for purchasing medicines. 95%. While collecting data in all 101 sample size was 44.55% did not have to spend money on investigations collected. whereas 55.44% had to spend some amount of money Simple random sampling method was adopted for investigations. On asking about the reasons for in conducting the study. A rural health centre was choosing this particular government health facility, selected purposely. The data was collected by using 40.59% patients replied that they trusted the doctors and a pre structured & pre tested proforma in the form of staffs. 38.61% said it was near their home hence they questionnaire. The data was filled using interview visited it for cure of their illnesses. 26.73% replied it was technique and questions related to Socio-demographic affordable to them and hence they visited this health care characteristics, general health assessment and the data facility. required for the study was collected. Before initiating Table 2 reveals female patients visited these the study, a rapport was build with the patients. They hospitals with complaints such as musculoskeletal pain were informed about the study purpose and consent was 36.63%, respiratory illnesses 24.75%, Gastrointestinal taken from them. They were assured of confidentiality complaints 19.80%, Antenatal Care 19.80%, injury and all the data thus gathered were kept confidential and 19.80%, ophthalmic complaints 08.91%, Genitourinary used for the study purpose. complaints 11.88%, Hypertension 08.91%, Diabetes Approval from the Institutional Ethics Committee Mellitus 03.96%, patients also visited other complaints (I.E.C) was obtained before starting of the study. The such as dental, skin, Ear Nose Throat and Piles 19.80%. study population was informed about the study purpose 12.87% had tobacco chewing addictions, 24.75% replied and written informed consent was taken from all of that they were addicted to gudakhu a form of tobacco them. They were assured of confidentiality and all the containing powder or paste for rubbing it on teeth and data thus gathered were kept confidential and used for gums and 3.96 responded to taking alcohol sometimes. the study purpose. Counseling, health education about 82 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3 shows the result of logistic regression that various health seeking behavior parameters with education as the dependent variable reveals the source of health facility (whether government or private), the modes of transportation and addiction among the female patients were significantly associated.
Table 1: Distribution of data according to health seeking behavior of the patients
Particulars Number n=101 Percentage
Source of health facility
Only government 52 51.48
Mostly private & sometimes government 12 11.89
Mostly government & sometimes private 37 36.63
Modes of transportation to reach the health facility
Walking 33 32.67
Bicycle 20 19.81
Motor vehicle or public transport 48 47.52
Time taken to reach the health facility
Less than 15 minutes 33 32.67
15 to 30 minutes 16 15.85
More than 30 minutes 52 51.48
Time between onset of symptom and visiting hospital
1 to 2 days 28 27.72
3 to 7 days 36 35.64
8 days to 1 month 08 07.93
> 1 month 29 28.71
Money spent for purchase of medicine
Free of Cost 81 80.19
100 to 200 16 15.84
>200 04 03.97
Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 83
Table 2: Distribution of data according to complaints and addictions of the female patients
Particulars Numbers n=101 Percentage
Complaints (Multiple responses)
ANC (Pregnancy) 20 19.80
Musculoskeletal Pains 37 36.63
Gastrointestinal complaints 20 19.80
Injury 20 19.80
Ophthalmic complaints 09 08.91
Genito-Urinary Tract infection 12 11.88
Hypertension 09 08.91
Diabetes Mellitus 04 03.96
Respiratory complaints 25 24.75
Sterilization operation 08 07.92
Jaundice 08 07.92
Malaria 08 07.92
Typhoid 04 03.96
Other (Dental, Skin, ENT, Piles etc.) 20 19.80
Addictions
Tobacco smoking 00 00.00 Addiction (n=29) (Multiple Tobacco chewing 13 12.87 responses) Tobacco paste (gudakhu) 25 24.75
No Addiction 72 71.28 84 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3: Association of health seeking behavior and education
Health facility B S.E. Wald df Sig. Exp (B) 95.0% C.I
Source of health facility -2.480 0.850 8.513 1 0.004* 0.084 0.016- 0.443
Symptom onset and visit 0.862 0.566 2.324 1 0.127 2.368 0.782- 7.176 to centre
Money spent on 0.670 0.786 0.726 1 0.394 1.954 0.419- 9.124 Medicine
Money spent on -0.114 0.602 0.036 1 0.850 0.892 0.274- 2.904 Investigation
Modes to reach health -0.931 0.463 4.054 1 0.044* 0.394 0.159- 0.976 centre
Time taken to reach -0.519 0.524 0.982 1 0.322 0.595 0.213- 1.661 centre
Addiction -3.215 1.065 9.122 1 0.003* 0.040 0.005- 0.323
*significant
Discussion money for laboratory investigations. 40.59% patients replied that they trusted the doctors and staffs. 38.61% From table 1 it was observed that 88.11% female said it was near their home so they visited it. 26.73% patients preferred government health care center and replied it was affordable to them and hence they visited 11.88% visited private hospital for treatment. Thus the this health care facility. Thus it is much evident from present study clearly reveals there is a preference for the time duration required to reach the centre and also government health facility over the private. In a similar most of them required transportation medium to reach observation in another study conducted by Deshmukh the health facility, suggesting that it is very far away SA in 2014 in Gadchiroli, Maharashtra, in India, it was from their home for majority. The major three factors observed that 27.9% patients visited government health assessed from the study for female patients visiting this facilities and 7% utilized the private hospitals in rural particular government health facility was its feature that areas for their health problems [8]. they had to spend less amount of money or none, they It can also be seen that 47.52% utilized some mode of trusted on the doctors, staff and this facility was near motor vehicle or public transportation to reach the health than other government health facility for some patients. center. 51.48% required more than 30 minutes to reach The Out of Pocket Expenditure (O.O.P.E.) even though the health center. 35.64% took 3 to 7 days after their less, still patients had to spend some amount of money illness to seek health care. 20.79% came after 1 month for purchase of medicines and laboratory investigations. to the hospital after their illness. 80.19% patients did In a similar observation another study conducted by not have to spend any amount of money for purchasing Musoke D 2014 in Africa it was observed that majority medicines. 55.44% had to spend some amount of of the participants (75%) used commercial motorcycles Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 85 to travel to health facilities while 18% walked. The rest (50%), respiratory and gastrointestinal problems used either bicycles (5%) or vehicles (2%). The study (41.58%), insomnia (22.27%), oral problems (15.84%), also observed that distance to health facilities affects skin and CNS disorders (15.34%) and genitourinary health services utilization. High cost of services and long problems (5.94%) [7]. distances to health facilities were the main challenges In a similar study by Thakur RP conducted in elderly established. Due to abolition of user fees at public and it was observed that majority of the population, health facilities, rural communities use them frequently. 45.6% belonged to the lower socioeconomic status. However, due to the limited number of public facilities 51.1% were married at the time of the survey. Overall, particularly in rural areas, inhabitants are necessitated to 14.5% had urinary symptoms. Overall, 44.7% of the use private health care providers at a cost [9]. population was found to suffer from arthritis [10]. Latunji OO in a similar study observed about The logistic regression results applied on the health seeking behavior that the most important service health seeking behavior of the female patients and factor affecting respondent’s choice of healthcare education reveals the source of health facility, the provider 34.5% of respondents considered the good modes of transportation to reach the health centre and services proximity (23.9%), affordability of services addiction among the female patients was significantly (20.4%), prompt attention (8.8%) and readily available associated and indicates that female patients did prefer drugs (7.1%). Politeness and courtesy among health government hospital over the private. Most of them had workers was least considered a factor in selecting to either travel through their personal or public transport healthcare provider (5.3%). Affordability (33.3%) was vehicles to reach the health centre. They were addicted the important reason for selecting health provider among to either tobacco or alcohol. Other parameters such as respondents who completed only basic education [4]. days after onset of symptoms and visit to health centre, Table 2 reveals female patients visited these hospitals money spent on purchase of medicine, money spent on with complaints such as musculoskeletal pain (36.63%), investigations and time taken to reach the health centre respiratory illnesses (24.75%), Gastro-intestinal was non- significantly associated. complaints (19.80%), Antenatal Care (19.80%), injury (19.80%), ophthalmic complaints 08.91%, Genito- Conclusions urinary complaints 11.88%, Hypertension 08.91%, Delay in seeking health care was observed. Out of Diabetes Mellitus 03.96%, patients also visited other Pocket Expenditure (OOPE) was evident from the study. complaints such as dental, skin, Ear Nose &Throat and This government health facility was nearest as compared Piles 19.80%. In table 4 it was revealed that around 40% to the other nearby government health facilities for the female patients were addicted to tobacco or alcohol. It can study population, it was affordable and a preferable be observed that there was an increase in health seeking choice for the rural patients due to trust on the doctors behavior for not only the musculoskeletal complaints and staff. Wide variety of health care services such as and respiratory problems but also some female patients diagnostic, curative was being provided in a rural health visited health care facility for seeking care for Antenatal care set up. Most of the female patients were addicted to care, sterilization operation and gynecological problems gudakhu an addictive tobacco product used in the form such as genitourinary complaints, Non communicable of rubbing the paste on gums. diseases, injury gastrointestinal problems and other complaints such as dental ailments clearly indicating Recommendations the wide variety of health care services being provided To reduce the delay in health seeking behavior in a rural health care set up. Chandrakar D in a study people are needed to be health educated about seeking conducted in a rural health centre in Maharashtra health care at the earliest and if there is a delay in health observed in elderly patients had wide range of health seeking behavior due to lack of local government health problems, out of which eye problems were reported by facilities, transport it needs to be solved or other issues 69.80% followed by cardiovascular problems (61.88%), such as pay cut from jobs for daily laborers, then may musculo-skeletal problems (51.98%), ENT problems be a suitable evening Out Patient Department timings 86 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
(OPDs) can be an answer to it which needs to be and psychological distress among elderly addressed appropriately. Technology and Internet can people in Northern India. Int J Epidemiol be utilized to help reach patients even in the remotest 2003;32:978-87. areas for minor ailments through mid level health 3. Borah H, Gogoi G, Saikia H. Health seeking workers which can reduce the burden of patients in behaviour of the mothers for illness of their under secondary and tertiary health centres and save time of five children in slums of Dibrugarh town. IntJ the patients which will drastically improve the health Community Med Public Health 2016;3:145-8. seeking behavior. Most of the patients in rural area 4. Latunji OO, Akinyemi OO. Factors Influencing belonged to lower socio economic group hence reducing Health-Seeking Behaviour Among Civil Servants In the OOPE is also recommended in order to improve the Ibadan, Nigeria. Ann Ib Postgrad Med 2018;16:52– health care seeking behavior of the patients in rural area. 60. Tobacco de-addiction and awareness about it harmful 5. Kumar H, Kapinakadu S, Anil M. Health seeking effects must be carried out in this area. behaviour and its determinants among rural population: a cross sectional study in South India. Acknowledgement: The authors thank all the Int J Community Med Public Health 2019;6:4944- participants who have participated in the study. 9. Conflict of Interest: There are no conflicts of 6. Das S and Das M. Health Seeking Behaviour and interest the Indian Health System. J Prev Med Holist Health 2017;3:47-51. Inclusion criteria of Author: 1.Principal 7. Chandrakar D, Prasad MA, Khapre M, Sharma M, investigator, drafting of manuscript & 2 literature search Ingole A, Wagh V et al. Health problems among and editing of manuscript elderly patients visiting primary health care centre Declaration: manuscript has been read and approved of Deoli block in Wardha district, central India: a by all the authors, the requirements for authorship as cross sectional study. J Acad Ind Res 2015;4:183-5. stated earlier in this document have been met, and each 8. Deshmukh SA, Kalkonde YV, Deshmukh author believes that the manuscript represents honest MD, Bang AA, Bang AT. Healthcare seeking behavior work. for back and Joint pain in rural Gadchiroli, India: A population-based cross-sectional study. Indian J References Community Med 2014;39:229-34. 1. Yerpude PN, Jogdand KS, Jogdand MS. A cross- sectional study of health problems and health 9. Musoke D, Boynton P, Butler C, Musoke MB. seeking behavior of aged population from rural Health seeking behaviour and challenges in utilising area of South India. Int J Health Sci Res 2014;4:29- health facilities in Wakiso district, Uganda. Afr Health 32. Sci 2014;14:1046–55. 2. Joshi K, Kumar R, Avasthi A. Morbidity 10. RP Thakur, A Banerjee, and VB Nikumb. profile and its relationship with disability Health Problems among the Elderly: A Cross-Sectional Study. Ann Med Health Sci Res 2013;3:19-25. DOI Number: 10.37506/ijphrd.v12i1.13834 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 87 Development of ICF based Assessment of Disability in Diabetic Neuropathy (ADDiN)
Manoj Abraham M 1, Ennapadam S Krishnamoorthy2, Vivek Misra, B3 1Principal, KG College of Physiotherapy (Affiliated to The TN Dr MGR Medical University), KG Hospital & PG Medical Institute, Coimbatore. Tamil Nadu, India, 2Founder and Chief Consultant, NeuroKrish, Chennai, 3Consultant – Neuromodulation and Innovations, The Institute of Neurological Sciences, Voluntary Health Sciences, Chennai and NeuroKrish, Chennai
Abstract Background: Diabetes Mellitus (DM) is a clinical syndrome which has an enormous impact on the immediate family, both in developed and developing countries. Assessment of Diabetic Poly Neuropathy (DPN) as a complication of DM becomes even more crucial. There is an urgent need to develop and validate an ICF based assessment on (DPN) relevant to our community life.
Methods: The list of ICF categories that were considered relevant and typical for DPN by experts was formulated, and the formulated assessment was christened as ADDiN (Assessment of Disability in Diabetic Peripheral Neuropathy). Following the ICF Core set for DM, current instrument ADDiN had 130 categories for DPN. The results showed that Cronbach’s Alpha Score for all the 5 domains was 0.730 and the 194 individual questions were analyzed and the score was 0.988, showing high reliability and consistency of the ADDiN scale.
Conclusion: The study results showing high sensitivity of ADDiN to DPN and fair specificity in differentiating DM from DPN, and high sensitivity and high specificity in differentiating DPN from control and high sensitivity and high specificity in differentiating DM from control suggests that ADDiN may be employed in future studies.
Key words: Prevalence of Diabetes, Diabetic Peripheral Neuropathy, ICF for Diabetes.
Introduction Worldwide prevalence of type 1 and type 2 DM is 366 million 2011, and by 2030 this would have risen to Diabetes Mellitus (DM) is a clinical syndrome 552 million. [2] Further, worldwide, 183 million people characterized by hyperglycemia due to absolute or with DM remain undiagnosed. DM caused 4.6 million relative deficiency of insulin.[1] DM is a chronic disease deaths and a sum of at least US465$ in health care that is prevalent in many countries. DM can arise in many expenditure in 2011. [3] It is estimated in 2011 that 61.3 different ways but is most commonly due to autoimmune million are diabetic in India. People with diabetes are type 1 diabetes or to adult-onset type 2 diabetes. more likely to experience limitations in mobility, social function, and activities of daily living.
According to the recent estimates by the International Corresponding author: Diabetes Federation (IDF), South East-Asia (SEA) Dr. Manoj Abraham M, Address- 69-1, Periyasamy Layout, Region consisting of India, Sri Lanka, Bangladesh, 5th Cross, Rathinapuri, Coimbatore- 641027. Bhutan, Mauritius and Maldives, is home to more than Email: [email protected] 72 million adults with diabetes in 2013 and is expected to Phone Number- 9442019495 exceed 123 million in 2035. Nearly 95% of people with ORCID = 0000-0002-7711-6461 diabetes have type II diabetes (T2DM). Although type I 88 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
diabetes (T1DM) is relatively rare in these countries, its motor symptoms usually occur late. prevalence is also rising. Elderly population contributed DPN ultimately results in the loss of both large and to 7% of the total population of India in 2001 and it will small diameter fibers, usually beginning with the small rise to 9% by 2016. In 2010,100 million people were fibers. Vascular changes, such as occluded vessels, aged above 60 years and by 2020 it will be 177 million. shunting and dilated capillaries, accompany progressive There are, however, patterns of diabetes incidence loss of nerve fiber. As DPN advances, the axons atrophy that are related to the geographical distribution of diabetes and are lost and the nerve is depopulated. This loss of in India. Rough estimates show that the prevalence of nerve fibers is responsible for the manifestation of DPN, diabetes in rural populations is one-quarter that of urban including ataxia, erectile dysfunction, abnormal position population for India and other Indian sub-continent sense and abnormal deep tendon reflex, as well as other countries such as Bangladesh, Nepal, Bhutan, and Sri micro vascular complications. Neuropathy is the most Lanka. [4] Preliminary results from a large community significant step in a series of events that culminates in study conducted by the Indian Council of Medical lower extremity complications of foot ulceration and research (ICMR) revealed that a lower proportion of amputation. Even minor trauma may produce skin the population is affected in states of Northern India ulceration, poor healing, and eventually gangrene. (Chandigarh 0.12 million, Jharkhand 0.96 million) as Even in the absence of lower extremity complications, compared to Maharashtra (9.2 million) and Tamil Nadu neuropathy can cause significant functional impairment, (4.8 million). [5] The National Urban Survey conducted including painful paresthesia, sensory ataxia and across the metropolitan cities of India reported similar Charcot arthropathy. Of the patients with diabetic trend: 11.7 per cent in Kolkata (Eastern India), 6.1 per neuropathy, 60–70% will develop serious complications cent in Kashmir Valley (Northern India), [6] 11.6 per that culminate in the amputation of an appendage. [11] cent in New Delhi (Northern India), and 9.3 per cent A recent study showed that DPN patients in West India (Mumbai) compared with (13.5 per cent experienced significant problems in 19 Categories in in Chennai (South India), 16.6 per cent in Hyderabad Body Functions, 3 Categories in Body Structures, 10 (south India) and 12.4 per cent Bangalore (South India). Categories in Activity and Participation and 4 Categories [7] A suggested explanation for this difference is that the in Environmental factors when compared with Diabetes north Indians are migrant Asian populations and south patients without Peripheral Neuropathy. [12] However, Indians are the host populations. [8] there are many published neuropathy composites scores The associated diabetic complications were available, [13] but there is no systematic framework that neuropathy (60%), Chronic Heart Disease (32.3%) and covers the spectrum of DPN symptoms and problems cataract (20%), retinopathy (15.4%), peripheral vascular in functioning in relevance to our community life have disease (11.5%) and cerebrovascular accidents (CVAs) been established thus far. Hence the need to develop and (6.9%). There was rise in the prevalence of all diabetic validate an ICF based assessment on (DPN) relevant complications with increase in the duration of diabetes. to our community life. Cultural differences exert a considerable impact on the applicability of individual Diabetic neuropathy (DN) refers to symptoms and categories in various countries. It was generalized signs of neuropathy in a patient with diabetes in whom that DM has an enormous impact on the immediate other causes of neuropathy have been excluded. Distal family, both in developed and developing countries, [14] symmetrical neuropathy is the commonest; accounting when DPN as a complication is added to DM, detailed for 75% DN. [9] DPN is often described as a stocking- assessment becomes even more crucial. Hence there is glove neuropathy, affecting the longest nerves before an urgent need to develop and validate an ICF based progressing proximally. [10] It usually presents with assessment on (DPN) relevant to our community life. sensory symptoms in toes or feet. In some patients neuropathy is mainly loss of feeling, it may present In this complex scenario of peripheral neuropathy with symptoms in the hand. DPN may or may not be of diabetes and serious lower limb complications, there accompanied by autonomic neuropathy. Significant is a felt urgency for a comprehensive assessment scale Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 89
for limb problems in diabetes, which would facilitate ICF categories were designated by the letters ‘b’ its early detection and prevent further complications, (Body Functions), ‘s’ (Body Structures), ‘d’ (Activities especially for therapists, who places locomotion as a and Participation), and ‘e’ (Environmental Factors). A top priority in human life. So the aim of the study is to comparison of the ICF core set with ADDiN is given create an ICF based Assessment of Disability in Diabetic below for a broad perspective. Neuropathy (ADDiN) The current version of the Comprehensive ICF Core Materials and Methods Set for DM has 99 categories, with 85 categories at the 2nd level of the classification and 14 categories at the 3rd level International Classification of Functioning, classification. The 99 categories of the Comprehensive Disability and Health (ICF) is World Health Organization ICF Core Set for DM are made up of 36 categories from (WHO) frame work for health and disability. [15] The Body Functions component, 16 categories from Body advantage of ICF is the application of it in clinical areas Structures component, 18 categories from Activities and development of condition specific health status and Participation component and 29 categories from measure. Both the Comprehensive ICF Core set and the Environmental Factors component. Following the ICF Brief Core set were referred, based on which this ICF Core set for DM, the current instrument ADDiN had based scale was developed. 130 categories for DPN consisting of 47 categories from After training in the ICF and based on preliminary the component ‘body functions’, 19 ‘body structures’, studies, relevant ICF categories for DPN were identified 27 ‘activities and participation’, and 37 ‘environmental by the researcher and placed before the experts from factors’. different background for a consensus. The expert team Main components of the ADDIN consisted of 10 members out of whom 2 were Physical therapists, 2 Neurologists, 2 Endocrinologists, 2 Body Function Component Epidemiologists and 1 Internal Medicine and 1 Social Workers. In DM there were 36 categories of the component body functions but were 47 categories of the component The Questionnaire and Methodology for this body functions were formulated for ADDiN. In DM out study was approved by Institutional Ethical Clearance of 36 categories 5 categories were at third level and no Certificate, Voluntary Health Services Hospital, Chennai. category in fourth level. But in ADDiN 12 categories The expert team met at The Institute of Neurological were at the third level and 3 are at fourth level of the Sciences, Voluntary Health Services, Multispecialty classification. In second level of body function category Hospital, Chennai, and deliberated on their knowledge b770 (gait pattern function) was included. In the third and expertise on ICF and DPN. The expert team was level of body function category which were included briefed about ICF and DPN. The consensus was arrived were b1301 (motivation), b1303 (craving), b2700 at to use ICF DM as reference and to identify of the most (sensitivity to temperature), b2701 (sensitivity to typical and relevant categories of the ICF for patients vibration), b2703 (sensitivity to noxious stimuli), b7101 with DPN. The expert survey using Delphi technique (mobility of several joints), b7304 (power of muscles of was conducted. The experts were given the autonomy all limbs). In the fourth level of category b28014 (pain to agree or disagree on a category included in DPN. in the upper limb), b28015 (pain in the lower limb) and The experts had to justify their decisions of inclusion b28016 (pain in joints) were included. or non-inclusion of categories. Data were collected in 3 rounds and answers were linked to the ICF and analyzed Body Structure Component for degree of consensus. The list of ICF categories 16 from the body structures component of DM were that were considered relevant and typical for DPN by in the comprehensive core set out of 16 categories 6 experts was formulated, and the formulated assessment categories were at third level and no category in fourth was christened as ADDiN (Assessment of Disability in level, but 19 from the body structures component of Diabetic Peripheral Neuropathy). ADDiN were included in which 11in level two, 8 at the 90 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 third level and no fourth level of the classification were Environmental Factors Component included. In second level of body structure category 29 from the environmental factors component of s730 (structure of upper extremity) was included. In the DM were in the comprehensive core set all 29 were third level of body structure category s7502 (structure in the second level, but in ADDiN and 37 from the of ankle and foot), s8102 (skin of upper extremity) and environmental factors component were included in which s8104 (skin of lower extremity) were included. all 37 were in level two, were included. In second level of Activities Limitation and Participation environmental category e120 (Product & technology for Restriction Component personal indoor & outdoor mobility & transportation), e145 (Products & technology for the practice of religion 18 from the activities and participation component & spirituality), e150 (Design, construction & building of DM were in the comprehensive core set out of products & technology of buildings for public use), 15 categories in second level, 3 categories were at e 155 (Design, construction & building products & third level, but in ADDiN 27 from the activities and technology of buildings for private use), e460 (Societal participation component were included in which 22 in attitude), e515 (Architecture & construction services, level two, 5 at the third level classification were included. systems & policies), e525 (Housing systems, services In second level of activity and participation category and policies), e540 (Transportation system, services and d230 (carrying out daily routine), d445 (hand and arm policies) was found relevant and was included in respect use), d460 (moving around in different locations), d470 to our country. (using transportation), d640 (doing house work), d910 (community life) in our diverse community life, d930 Prompts (religion and spirituality) felt that it was essential to After the pilot study the researcher and the experts include this as it was very relevant to our place or country felt that some of the questions were too complex for many of the illiterate subjects. So prompts were developed and used.
For example, b2700 Sensitivity to temperature Sensory functions of sensing cold and heat Question: Do you have problem sensing heat or cold? Prompts: Are you able to tell that the coffee in your tumbler is hot. When you handle the metal tumbler? Have you walked barefoot on the tar road and not felt the heat and known only after you noticed the blisters on your feet? d930 Religion and spirituality Engaging in religious or spiritual activities Question: Do you have difficulty in engaging in religion and spirituality? Prompt: Do you have difficulty in attending Church/ temple/mosque/ etc? And also indulging in your practices
Prompts were developed for all the 130 questions For example and were culture specific questions.
Verbatim b1303 Craving Prompt: Do you crave for food, sweet etc? Another inclusion was to use Verbatim for all the Verbatim: questions, in addition to the answers obtained. Verbatim Specify: is the exactly using the same words the subjects used in answering the question. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 91
Additional Information with culture or social strata specific indicators from a developing nation Another inclusion was to use the specific terms relevant to gather more rich qualitative data of All the team members felt that the inclusions and significance from the subjects. The assessments were exclusions (Table 1) were essential and Delphi consensus recorded and anything in excess of the format were was once again used and agreed on the revisions to be included in a separate column created for this purpose executed in the main study. It took approximately 45 89 only. This we felt would enhance qualitative data minutes to 1 hour to administer ADDiN.
TABLE 1: INCLUSIONS AND EXCLUSIONS AFTER DELPHI STUDY
Inclusions Exclusions
Body structure category structure of Pain Quality assessment scale nails in hand and feet
Medical Research Council MRC grading of muscle
Range of motion in individual joints
Structure of skin in upper extremity and lower extremity
Activity limitation and participation restriction carrying out daily routines
Wearing and taking off footwear
Environmental factors the societal attitude
Prompts
Tamil translation
Verbatim
Additional information
Results respectively. Environmental Barrier and Facilitator domain was 0.986 and 0.998 respectively. The Reliability of ADDIN Reliability and internal consistency of ADDiN analyzed The reliability of ADDiN was analyzed using using Cronbach’s Alpha and was found to be reliable. Cronbach’s Alpha. The body function domain was The Cronbach’s Alpha Score for all the 5 domains 0.874. The body structure domain was 0.242 which was was 0.730 and the 194 individual questions was analyzed low on reliability and consistency. Activity limitation and the score was 0.988, showing high reliability and and participation restriction was 0.837 and 0.915 consistency of the ADDiN scale. (Table 2 and 3) 92 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
TABLE 2: THE CRONBACH’S ALPHA SCORE FOR THE BODY FUNCTIONS, BODY STRUCTURE, ACTIVITY AND PARTICIPATION AND ENVIRONMENTAL DOMAIN IN ADDiN
Domain Cronbach’s Alpha N of items
Body Function 0.87 47
Body Structure 0.24 19
Participation Restriction 0.84 27
Activity Limitation 0.91 27
Environmental Barrier 0.97 37
Environmental Facilitator 0.99 37
TABLE 3: THE CRONBACH’S ALPHA SCORE FOR ALL THE INDIVIDUAL QUESTIONS IN ADDiN
Cronbach’s Alpha N of items
0.99 194
Discussion The study results showing high sensitivity of ADDiN to DPN and fair specificity in differentiating ADDiN consisting of 47 (36%) categories from DM from DPN, and high sensitivity and high specificity the component ‘Body Functions’, 19 (15%) ‘Body in differentiating DPN from control and high sensitivity Structures’, 27 (20%) ‘Activities and Participation’, and high specificity in differentiating DM from control and 37 (29%) ‘Environmental factors’ was used to suggests that ADDiN may be employed in future studies. measure disability in DPN. The Reliability and internal No doubt modification of the body structure component consistency of ADDiN was found to be good except has potential to further increase the specificity of the in the body structure domain. The low score perhaps instrument without a significant drop in sensitivity, given reflects the approach taken to adapt ICF DM as reference that the overlap between DM and DPN components may and to develop the ICF based scale ADDiN for DPN. have compromised specificity more so than sensitivity. The result suggests that the body structure domain which was relevant to DM may not be relevant to DPN and that Acknowledgement this section may require further modification prior to its use in wider populations. Nevertheless the overall results The Authors sincerely thank Dr. Ennapadam S suggest that ADDiN is a good scale with reliability and Krishnamoorthy, Founder and Chief Consultant of internal consistency indicating it can be used as ICF NeuroKrish, Chennai, and the Expert team members for based assessment for DPN. their support and logistical help to conduct this research. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 93
Funding: No funding was received for conducting 7. Ramachandran A, Snehalatha C, Kapur A, Vijay V, this study Mohan V, Das AK, Rao PV, Yajnik CS, Prasanna Kumar KM, Nair JD. Diabetes Epidemiology Scale copyright: Dairy number 10173/2018-CO/L Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India: Conflict of Interest: The authors have no conflict National Urban Diabetes Survey. Diabetologia of interest to declare that are relevant to the content of 2001; 44(9):1094–101 this article 8. Arora V, Malik JS, Khanna P, Goyal N, Kumar References N, Singh M. Prevalence of diabetes in urban Haryana. Australas Med J. 2010; 3(8):488–94 1. Nicki R. Colledge Stuart H. Ralston, Brian R. 9. V Bansal, J Kalita, and U K Misra. Diabetic Walker. Davidson’s Principles and Practice of neuropathy. Postgrad Med J 2006; 82(964): 95–100 Medicine- 21th Edition, Churchill-Livingstone Elsevier, 2010 10. David R. Cornblath, Diabetic neuropathy: Diagnostic methods Adv Stud Med 2004: 650–61. 2. Sarah Wild et al, Estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 11. Boulton AJ. Treatments for diabetic neuropathy. 27(5):1047–1053 Curr Diab Rep. 2001; 1:127–32. 3. Diabetic Atlas 5th Edition, © International Diabetes 12. Sobia Fatma and Majumi M. Noohu. Classification Federation, 2011 of functionality of people with Diabetic Peripheral Neuropathy based on International Classification of 4. Wild S, Roglic G, Green A, Sicree R, King H. Functioning, Disability and Health Core Set (ICF - Global prevalence of diabetes-estimates for the CS) of Diabetes Mellitus. Journal of Diabetes and year 2000 and projections for 2030. Diabetes Care Metabolic Disorders 2020; 19: 213-221 (Newly 2004;27(3):1047–53 added reference) 5. Anjana RM, Ali MK, Pradeepa R, Deepa M, Datta 13. Ruof J, Cieza A, Wolff B, Angst F, Ergeletzis D, M, Unnikrishnan R, Rema M, Mohan V. The Omar Z, et al. ICF Core Sets for diabetes mellitus. need for obtaining accurate nationwide estimates J. Rehabil. Med 2004 ; 44:100–6. of diabetes prevalence in India - rationale for a national study on diabetes. Indian J Med Res. 2011; 14. Chiu WT, Yen CF, Teng SW, Liao HF, Chang KH, 133:369–80 Chi WC, et al. Implementing disability evaluation and welfare services based on the framework of 6. Zargar AH, Khan AK, Masoodi SR, Laway BA, the international classification of functioning, Wani AI, Bashir MI, Dar FA. Prevalence of disability and health: experiences in Taiwan. BMC type 2 diabetes mellitus and impaired glucose Health Serv Res 2013; 13:416. tolerance in the Kashmir Valley of the Indian subcontinent. Diabetes Res Clin Pract. 2000; 15. Ustun TB, Chatterji S, Kostansjek N, Bickenbach 47(2):135–46 J. WHO’s ICF and functional status information in health records. Health Care Financ. Rev 2003; 24(3):77–88. 94 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13835 Prevalence and Profile of Device Associated Infection in Precisely Tribal Sickle Cell Disease children above 10 years of Age Admitted to ICU of a Tertiary Care Hospital of Tribal Area
Monalisa Subudhi1, P.A.T.Jagatheeswary 2, Sudhanshu Kumar Das3, Arakhita Swain4, Rashmi Ranjan Rout5 1Assistant Professor, Dept of Microbiology, Gayatri Vidya Parishad Institute of Health Care &Medical Technology ,Visakhapatnam, AP , 2 Professor , Dept of Microbiology ,Saveetha Institute of medical & Technical Science , Chennai ,TN, 3,* Associate Professor, Dept of Pediatrics , Gayatri Vidya Parishad Institute of Health Care &MedicalTechnology, Visakhapatnam, AP , 4 Professor & HOD , Dept of Pediatrics, SLN medical college, Koraput. Odisha, 5 Tutor, Dept of Microbiology,SLN medical college, Koraput. Odisha
Abstract Background:Sickle cell disease (SCD) children are more susceptible to bacterial infection due to multifactorial causewith poorimmunization status in tribal area.Device associated infections (DAIs) , due to extensive use of invasive devices in intensive care units , further increases morbidity and mortality in these patients . In the present study ,our aim is to define , the total burden and profile of DAI as presentation , spectrum of bacterial isolate and susceptibility in SCD children, in specific to, ICU of a tertiary care Hospital in Tribal area. Methodology:This prospective study was conducted overDevice Associated infections (DAIs) in Sickle cell disease (SCD) tribal children, having an inserted indwelling device, in the ICU of atertiary care hospital.Demographic ,clinical and date of device insertion data were recorded . Depending on the type of specimen, samples were cultured and analyzed .Antimicrobial susceptibility testing was performed on different isolates. Result: Out of 31 exposed SCD children to indwelling devices,the confirmed DAI cases were, 1 central line-associated bloodstream infections (CLABSI), 1 ventilator-associated pneumonia (VAP), and 3 catheter-associated urinary tract infections (CAUTI ). The overall DAI rate was 16.1% with 29.7 per 1000 device days . The Organism causing infection were Gram-negative in 3(60% ) cases , Gram-positive in 2 (40% ), and as mixed infection with fungal organisms in 2( 40%) cases. Most isolates were susceptible to Co-Trimoxazole , Ceftriaxone and Gentamycin . CONS and Klebsiella were showing multidrugresistant to more antibiotics tested.Conclusion:Since,In view of high DAIrate in Sickle cell Disease Tribal children in the ICU of tribal area,the preventive strategies should be plannednot only to improve immunity but also reduce morbidity ,mortality , to ensure a good quality health care in them.
Key Word - Sickle cell disease (SCD), Device Associated infections (DAI), Central line-associated bloodstream infections (CLABSI), Ventilator-associated pneumonia (VAP), Catheter-associated urinary tract infections (CAUTI).
Introduction genetic disorder of the haemoglobin in red cells. It is Sickle cell disease (SCD) is an autosomal recessive particularly disastrous, mainly due to its acute and chronic complication such as painful vaso-oclusive Corresponding Author: events, acute chest syndrome and acterial infections. Dr Sudhanshu kumar Das, (MD) Bacterial infections ,the commonest etiological agent Associate Professor, Dept of Pediatrics, Streptococcus pneumonia have been shown to be the Teaching Staff Quarter, #25 Gayatri Vidya Parishad major cause of death in children with sickle cell disease. Institute of Health, care & medical technology , [1],[2],[3] The cause of increase susceptibility of SCD Visakhapatnam, AP Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 95
patients to Bacterial infection is multifactorial including between March 2019 and February 2020 . This Study defect in compliment activation ,functional asplenia, was reviewed and approved on 28th February 2019 by micronutrient deficiencies.[4] There is a predominance the ethical committee of research review board of our of invasive pneumococcal infection below the age of hospital. five and salmonella infection above five years oldin Among all SCD children above 10 yearsin our 20 SCD children.[5],[6] bedded ICU, confirmed earlier or newly diagnosed Device Associated infections (DAIs) due to ( by Sickling Test and High performance Liquid extensive use of invasive devices in patients, are a major Chromatography ), who fulfilled the definitions of cause of morbidity and mortality in intensive care units CLABSI or VAP or CAUTI as defined by the CDC’s .The DAI rate in an ICU also depends upon a number National Nosocomial Infections Surveillance (NNIS) of factors such as type of patient admitted, condition of system criteria, at any point during their stay in the ICU patient , use of antibiotics ,protocol of using indwelling were taken . The definitions of CLABSI, VAP, and CAUTI devices and infection control in these settings . In most were adapted from CDC. The first CDC criterion for any hospitals, the ICU-acquired infections account for more of the three infections is that they must have occurred at than 20% of all nosocomial infections.[7] The World least on the second day of placement of the respective Health Organization (WHO) assessed the rates of DA- device. Second, if the device was removed after two days HAIs in the ICUs of low- and middle income countries of placement or more, an infection occurring, at most, on in a systematic review , where the rate of CLABSI was the day following the removal of the device was also 12.2 per 1,000 central line-days, CAUTI was 12.2 per considered to be associated with the respective device. 1,000 urinary catheter-days, and VAP was 23.9 per Inclusion criteria: 1. Children who were confirmed 1,000 ventilator-days .[ 8] early or newly diagnosed in ICU , 2.SCD children above the age of 10 years.3. SCD children having at least one Further, DAI in infection prone sickle cell disease of a placed central line, endotracheal tube, or Foley children will increase mortality and morbidity rate in catheter in the PICU. 4. SCD children who fulfilled the PICUs. In a multicentre study conducted in ICUs in definition of CLABSI, VAP, and/or CAUTI .5 . Those India, mortality due to VAP, CR-UTI, and CR-BSI were admitted in PICU for more than 48 hours were included 19 0%, 11 6%, and 4 0% respectively .[9] in the study , 5. Tribal area SCD children. So, the DA-HAI surveillance played an important Exclusion criteria:1.Children other than SCD role in reducing the rates of DAIs and improving admitted to ICU. 2. SCD Children below 10 years of age hospital infection control and quality assurance in . 3. SCD Children neither having at least one of a placed developed countries.[10],[11] To our knowledge, there central line, endotracheal tube, or Foley catheter in the are no published data on the burden and spectrum of ICU nor fulfilled the definition of CLABSI, VAP, and/or bacteria and outcome in Device associated infection CAUTI.4. Infection other than DAI. , in SCD childrenin the PICU . In the present study ,our aim is to define , the total burden and profile of Sample Collection In all suspected DAI in the DAI as presentation , spectrum of bacterial isolate and presence of a device cases, susceptibility in tribal SCD children, in specific to , ICU The most appropriate samples for the diagnosis of a tertiary care Hospital in Tribal area of a site-specific DAI were collected aseptically Methodology for microbiology analysis and sent to microbiology laboratory without delay. In case of CA-UTI, urine was Study Design & Setting : This was a Prospective collected suprapubically with a sterile needle and syringe study that included all SCD children , having at least one and distal 5 cm of the aseptically removed urinary of a placed central line, Endotracheal tube, or Foley’s catheter was cut and sent to microbiology .Deep tracheal catheter and fulfilled the definitions of CLABSI, VAP, aspirates or distal 5 cm of used ET tube were collected and/or CAUTI at any point during their stay in the aseptically for VAP. In case of CLABSI, catheter line was ICU of SLN medical college, a tertiary care hospital , removed aseptically; the distal 5 cm of the IV catheter 96 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 was cut and sent to microbiology laboratory along with recorded. Clinical data as sign, symptom at the time of the blood collected for culture from the other arm. admission and new symptoms after placement of central . Infection surveillance and consent form with necessary line or endotracheal tube or urethral catheter were details was filled up simultaneously .Qualitative cultures collected . were performed on peripheral or central blood, deep tracheal aspirate or from ET tube, and quantitative Statistical Analysis cultures were done on urine samples. For urine, a count Microsoft Excel was used for data entry and analyzed 5 of more than 10 colony-forming units per ml with with SPSS software version 20.0 . For quantitative one or two micro-organisms isolated was considered variable , median and for qualitative variable ,frequency as a confirmation of UTI. Standard culture methods (percentage ) were used to present the results. were used, to identify the microorganism , depending on the type of specimen to be analysed,. Antimicrobial Results susceptibility testing was performed on isolates . In the present study ,a total of 56 SCD tribal Data Collection children treated for an aggregated duration of 518 days with different complaint, were taken. Out of these, 31 In all cases , demographic data (Age ,Sex, Address,) SCD tribal children were exposed to various devices ,vaccine status, date of admission, duration of Stay, type for a total duration of 206 device days with a overall of devices inserted along with the time and date were Device utilization rate of 0. 39 . The overall DAI rate was 16.1% with 29.7 per 1000 device days .(Table-2)
Table :1 Demographic data of SCD Tribal children.
SCD Children admitted to ICU Total ( n= 56 ) Sex Total (n) Percentage (%)
Male 14 45.1 % SCD children with various Indwelling Devices 31(55.3%) (Exposed) Female 17 54.8 %
Male 18 72 % SCD children without Indwelling Devices ( Not 25( 44.6%%) Exposed) Female 7 28 %
Male 2 40% SCD children with Confirmed DAI 5 (16.1%) Female 3 60%
Out of 56 SCD children , 31(55.3%) exposed to different indwelling devices , where 14 ( 45.1%)male and 17 (54.8 %) were female patients .Only 5(16.1%) cases confirmed by microbiologically as DAI . (Table-1) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 97
Table-2 :Distribution of SCD tribal children in ICU according to Clinical presentation and Rate of DAI per specific site of Infection.
AA( Acute Abdomen ), ACS- Acute chest syndrome , SS-Septicemia, SP- Severe Pneumonia, FUO- Fever of Unknown Origin, PC-Pain crisis, SA- Severe anaemia
The SCD tribal children admitted in ICU with admission and kept at least for 5 days , Where as in VAP cause were , Acute abdomen 3/10 ( 30%) , Acute chest and CAUTI patients , Endotracheal tube and urinary nd rd syndrome 8/10 (80 % ), Septicemia 9/9 ( 100 % ), Severe catheter inserted on 2 or 3 day of ICU admission and pneumonia 10/10 (100% ), Fever of Unknown Origin kept for at least for 3 and 7 days respectively. Total no 12/13 (92.3 %), Pain crisis 0/9 (0%), Severe anaemia of Device day was 206 days ,where for central line 51 2/3(66.6%) . A total of 31 Device exposed patients days ,endotracheal tube 34days and urinary catheter 121 were identified with 10 (32.2%) central line-associated days. So the DAI rate per site of infection were CLABSI bloodstream infections (CLABSI), 6 (19.3%) ventilator- 1(10%) with 19.6 per 1000 device days ,VAP 1 (16.6%) associated pneumonia (VAP), and 28 (90.3%) catheter- with29.4 per 1000 device days , CAUTI 3(10.7%) with associated urinary tract infections (CAUTI). In CLABSI 24.7 per 1000 device days .(Table-2) patients, Central line inserted on 1st or 2nd day of ICU
Table-3 :Distribution of microorganisms per site of( Single / Mixed infection ) infection.
CLABSI VAP CAUTI Total (n= 5) Microorganism Single Mixed Single Mixed Coagulase-negative Staphylococcus 0 1 0 1 (20%) (CONS) Streptococcus Pneumonae 1 0 0 1 (20%)
Escherichia coli 0 0 1 1 (20%)
Candida albicans 0 1 0 1 2 (40%)
Pseudomonas aeruginosa 0 1 1 (20%) Klebsiella Pneumoniae 1 1 (20%) 98 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
DAIs in Sickle cell Disease Tribal children in the Pneumoniae in 1 (20%) case each . In some sites we got ICU were caused by Coagulase-negative staphylococci mixed infection with two or more organisms. Overall (CONS) in 1 (20%) case , Streptococcus Pneumonae in 1 ,Gram-negative pathogens in 3(60% ) , Gram-positive (20%) case , Escherichia coli in 1 (20%), Candida species ones in 2 (40% ), and fungal organisms in 2(40%) as 2 (40%) and Pseudomonas aeruginosa, Klebsiella mixed infection , were found in these children .(Table-3)
Table-4 :Sensitivity pattern of the bacteria isolated from SCD children with DAI to some antibiotics.
Isolates susceptible to different antibiotics Name of Organism GMN AMX VAN COT CZM CTZ CPZ IMP CTX NF LZ CFX
Coagulase-negative 0 0 1 0 0 0 0 0 1 0 0 0 Staphylococcus
Streptococcus 0 1 1 1 0 1 0 0 1 0 1 1 Pneumonae
Escherichia coli 1 1 0 1 1 1 0 1 1 1 1 1
Klebsiella 1 0 0 0 1 0 0 1 0 1 0 Pneumoniae
Pseudomonas 0 0 0 1 1 1 0 1 1 0 0 0 aeruginosa
GMN-Gentamycin,AMX-Amoxycillin,VAN-Vancomycin,COT-Co-Trimoxazole,CZM-Ceftazidim,CTX- Cefotaxime ,AMK- Amikacin ,CPZ – Cefoperazone ,IMP- Imipenem , CTZ-Ceftriazone, NF-Nitrofurantoin, LZ- Linezolide, CFX-Cefuroxime
In the present study, most of the isolates were found Discussion susceptible to Co-Trimoxazole , Ceftriaxone ,cefotaxime, The place of study is a tertiary care hospital in the imipenem and Gentamycin. The susceptibility rate tribal area ,covering a large population and the border of Enterobacteriaceae members (Escherichia coli and of another state , where Consanguineous marriage at Klebsiella pneumoniae) were found to be more with second degree is more. . These people are also migrated Gentamycin, Imipenem and Ceftazidime. Overall to this place , hence genetic diseases are expected more susceptibility of Escherichia coli isolates was better . Again. because of unawareness ,and lack of health than Klebsiella isolates for most of the antibiotics consciousness , the immunization status of these SCD tested. Klebsiella isolates were resistant to Vancomycin children is poor , which make them more prone for and Co-Trimoxazole. Among the gram positive bacteria infection leading to more ICU admission .So we decided Streptococcus Pneumonae was susceptible to most to do study over these children for better outcome in the of the antibiotic as compared to CONS., where as ICU . Out of 56 SCD tribal children, only 31(55.3%) CONS was resistant to Gentamycin and Co trimoxazole were exposed to different invasive devices, where ,Amoxycillin . Pseudomonas aeruginosa wassusceptible females 17(54.8%) and male 14( 45.1 %) cases . to ceftazidime, ceftriaxone, Imipenem and resistant to (Table-1) gentamycin.. For Candida species we have not done any susceptibility test. (Table-4) In the present study ,out of 31 exposed SCD children, 5 patients were microbiologically confirmed Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 99
cases as DAI. . The overall DAI rate was 16.1% with another study by Priyanka et al ,where VAP rate was 29.7 per 1000 device days (Table-1) , which was more 31.74 per 1000 ventilator-days with 0.46 DUR .[22] as compared to a study in Thai PICU, where the rate of In the present study, CAUTI was the most common DAIs was 28.3 per 1,000 patient-days, [12] and to an type of DAI in our ICU, followed by CLABSI and VAP another study in Egypt from two PICUs by INICC ,were (Table-2). These results are against to those found in 22.8 DAHAIs per 1,000 ICU-days .[13] For DAI in ICU other developing countries, where VAP is the most setting , the findings of the International Nosocomial common cause of DAIs, and similar to the high-income Infection Control Consortium (INICC) in ICUs of seven countries, where CAUTI is the most common type in Indian cities had found overall infection rate of 4.4%. [14] PICU in children .[8] . It showed that ,even if the device utilization rate was less ,the device infection rate in our study in SCD children All DAI rate of specific site in our study were was high. This high DAI rate in SCD children , might be more to a study on children other than SCD in PICU due to all are improperly immunized ,sick and referral in Egypt by INICC reported 18.8 CLABSIs per 1,000 cases . Again the sample size was small as compared to line-days, and 31.8 VAPs per 1,000 ventilator-days utilization of indwelling devices in our ICU . .[13] It revealed that the DAI ( CAUTI &CLABSI ) in SCD tribal children in our ICU was more than non SCD To determine the CLABSI in ICU ,a total of children in the ICU , because of infection prone poorly 10(32.2%) were exposed to the central line over a immunized children and also not following properly the period of 51 Device days , from where only 1 (10%) protocol to prevent DAI or delay in using antibiotics case was confirmed as DAI ,resulting in an infection therapeutically and prophylactically . VAP is less due to rate of 10% with 19.6 per 1000 device days . It was frequent changing of endotracheal tube prophylactically more in comparison to a study by INICC in Egypt because of tube block . from two PICUs, reported 18.8 CLABSIs per 1,000 [13] line-days, and 31.8 VAPs per 1,000 ventilator-days The organisms isolated in the present study were and quite high to a study in US and Turkish rates of 3.2 Coagulase-negative staphylococci,Streptococcus [15] and 9.69 infections per 1000 device days and less Pneumoniae, Candida albican, Escherichia coli , to peripheral line related blood stream infection rates of Klebsiella Pneumoniae .(Table-3) Which was similar to [16],[17], 0.3 to 31.1% . findings in other studies [14]. ,[23] Staphylococcus aureus(1 CLABSI and 1 VAP) was the most common cause of In order to know the CAUTI, 28 patients were DAIs, followed by Candida species ( 1CLABSI and 1 undergone urinary catheterization, with a total of 121 CAUTI) as mixed infection followed by Escherichia Device days . Only 3 cases were confirmed as DAI coli (1 CAUTI), which was different from the nosocomial microbiologically ensuing a rate of 10.7 % with 24.7 infections among PICU patients in an another study in per 1000 device days. This was more as compared to Alexandria, Egypt , [24] where Klebsiella species were 6.8 CA-UTI per 1000 device days in one study by the most commonly isolated pathogens (46.7%), but Vonberg et al. [18] High CAUTI rate may be due to more having some similarity to a study done in the Arab female patient as compared to male , even after the high region of Tunis ,[25] showed Staphylococcus aureus risk of infection in SCD children . to be the most common cause (26.8%) of nosocomial In our study , We studied 6 intubated patients kept bloodstream infections, followed by coagulase-negative on ventilators, for 34 device days in order to determine staphylococci (17%). the VAP . Out of which , only 1 patients was confirmed Most of the isolates were found susceptible to VAP with an infection rate of 16.6% with 29.4 per 1000 Co-Trimoxazole , Ceftriaxone and Gentamycin. The device days; which was high or near to that of a Turkish susceptibility rate of Enterobacteriaceae members study, reporting a rate of 20.8% with 24.1 infections per (Escherichia coli and Klebsiella pneumoniae) were 1000 device days, [19],[20] and same to other different found to be more with Gentamycin, Imipenem and studies ,where the rates of VAP had ranged from 10.5 Ceftazidime. Among the gram positive bacteria ,Staph to 34.8% .[14],[16],[19],[21] But it was less as compared to aureus were susceptible to most of the antibiotic as 100 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 compared to CONS. All the organisms isolated in the syndrome in Cameroonian children living with present study were showing some resistant to more than Sickle cell Disease .BMC Pediatric 2015;15:131. two different classes of antibiotics .Mostly CONS and 4. Catherine Booth , Baba Inusa, Stephen K Obaro Klebsiella were showing multidrug resistant to more et al :Infection in Sickle cell Disease.a review. antibiotics tested. (Table-4) International Journal Infectious Disease.2010 ;14(1):e2-e11. However ,our study had some limitations, we did 5. Burnet MW, Bass JW, Cook BA . Etiology of not search for viral and sensitivity pattern for Fungal osteomyelitis complicating sickle cell disease. agent in these SCD tribal children . we have not Official journal of academy of Pediatric followed up of DAI patients to find out DAI associated 1998;101(2):296-7. morbidity and mortality . 6. ZarkwoskyHS, Gallagher D, Gill FM, Wang WC, FalletaJM, lende VM et al .Bacteremia in Sickle Conclusion Hemoglobinopathies. The Journal of Pediatric To reduce mortality and morbidity in Tribal Sickle 1986;109(4):579-85. Cell Disease children with DAI in the ICU, a preventive 7. Fridkin SK, Welbel SF, Weinstein RA Magnitude strategies such as antibiotic policy, protocol for using and prevention of nosocomial infections in the device , proper immunisation and at the same time better intensive care unit. Infectious Disease Clinic North quality of life to improve immunity and quality health America 1997;11: 479-96. care in ICU of any hospital in Tribal area should be 8. World Health Organization (2010) The burden planned . Hence regular surveillance of device-associated of health care associated infection worldwide. infections in ICU is therefore highly informative not Available:http://www.who.int/gpsc/country_work/ only to clinicians but also to administration, specifically burden_hcai/en. Accessed in September 2014. for these children in the tribal area , in determining the 9. MehtaA ,Rosenthal V D, Mehta Y, Chakravarthy burden and type of infection , rateand risk factor. M, Todi S K, Sen N, et al . Device-associated nosocomial infection rates in intensive care units Recommendation of seven Indian cities Findings of the International Keeping in mind the chance of DAI rate in Sickle Nosocomial Infection Control Consortium (INICC) . Journal of Hospital Infection 2007; 67:168-74. Cell Disease children, more surveillance studywith large sample size over tribal children should be done in the 10. Rosenthal VD, Maki DG, Mehta A, Alvarez-Moreno ICU of hospital in tribal area . C, Leblebicioglu H, Higuera F et al . International Nosocomial Infection Control Consortium report, Funding: No funding sources data summary for 2002-2007, issued January 2008. America Journal of Infection Control 2008; 36: Conflict of Interest: No 627-37. 11. Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen- References Bridson K, Morrell G et al .National Healthcare 1. Julie A Panepinto 1, Kerry M O’Mahar, Michael R Safety Network (NHSN) report: data summary DeBaun, Fausto R Loberiza, J P Scott et al .Health for 2006 - 2008, issued December 2009. America related quality of life in Sickle cell Disease children Journal of Infection Control 2009;37: 783-805. :child and Parent perception. British Journal of 12. Sritippayawan S, Sri-Singh K, Prapphal N, Hematology 2005; 130(3):437-44. Samransamruajkit R, Deerojanawong J . Multidrug- 2. Miller AC ,Gladwin MT et al. Pulmonary resistant hospital associated infections in a pediatric complication of Sickle cell Disease . America intensive care unit: a cross sectional survey in a Journal of Respiratory and critical care Med 2012; Thai university hospital. International Journal of 185(11):1154-65. Infect Disease 2009; 13: 506-12. 3. Jobert Richie N. Nansseu, Anastasie Nicole Alima 13. Rasslan O, Seliem ZS, Ghazi IA, El Sabour MA, Yanda, David Chelo, Sandra A. Tatah, Hubert D. El Kholy AA, Sadeq FM et al . 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care units of hospitals in Egypt. International 20. Inan D, Saba R, Yalcin AN, Yilmaz M, Ongut Nosocomial Infection Control Consortium (INICC) G, Ramazanoglu A, et al. Device-associated findings. Journal of Infection and Public Health nosocomial infection rates in Turkish medical- 2012; 5: 394-402 surgical intensive care units. Infection Control and 14. Mehta A, Rosenthal VD, Mehta Y, Chakravarthy Hospital Epidemiology 2006;27:343-8. M, Todi SK, Sen N, et al. Device associated 21. Balkhy HH, Cunningham G, Chew FK, Francis C, nosocomial infection rates in intensive care units Al Nakhli DJ, Almuneef MA, et al. Hospital and of seven Indian cities. Findings of the International community acquired infection: a point prevalence Nosocomial Infection Control Consortium and risk factor survey in a tertiary care center in (INICC). J Hosp Infect 2007;67:168-74. Saudi Arabia. Int J Infect Dis 2006;10:326-33. 15. Leblebicioglu H, Rosenthal VD, Arikan OA, 22. Priyanka Udawat, Shalu Gupta, Vikas Manchanda, Ozgόltekin A, Yalcin AN, Koksal I, et al. DigantaSaikia et al. Clinico-microbiological Device-associated hospital-acquired infection profile of Health care associated infectionin rates in Turkish intensive care units. Findings of pediatric intensive care unit of tertiary care the International Nosocomial Infection Control hospital.,International Journal of Contemporary Consortium (INICC). Journal of Hospital Infection Pediatrics2017;4(2):577-85 2007;65:251-7. 23. National Nosocomial Infections Surveillance 16. Bennett NJ, Bull AL, Dunt DR, McBryde E, Russo System. National Nosocomial Infections PL, Spelman DW, et al. Bloodstream infection Surveillance (NNIS) System Report, data summary surveillance in smaller hospitals. Australian Infect from January 1992 through June 2004, issued Control 2007;12:45-7. October 2004. America Journal of infection 17. Akash D, Ghildiyal R, Kandian S, Shinkre N. Control 2004;32:470-85. Clinical and Microbiological Profile of Nosocomial 24. El-Nawawy AA, El-Fattah MMA, Metwally Infections in the Pediatric Intensive Care Unit HAE-R, Barakat SSED, Hassan IAR. One (PICU). Indian Pediatric 2004;41:1238-46. Year Study of Bacterial and Fungal Nosocomial 18. Vonberg RP, Behnke M, Geffers C, Sohr D, Ruden Infections among Patients in Pediatric Intensive H, Dettenkofer M, et al. Device associated infection Care Unit (PICU) in Alexandria. Journal of rates for non-intensive care unit patients. Infection Tropical Pediatric 2006;52: 185-91. Control and Hospital Epidemiology 2006;27:357- 25. Jaballah NB, Bouziri A, Mnif K, Hamdi A, Khaldi 61. A, Kchaou W et al. Epidemiology of hospital- 19. Rosenthal VD, Maki DG, Salomao R, Moreno acquired bloodstream infections in a Tunisian CA, Metha Y, Higuera F, et al. Device associated pediatric intensive care unit: A 2-year prospective infection in 55 Intensive Care Units of 8 developing study. American Journal of Infection Control2007; countries. Annals of Internal Medicine -ACP 35: 613-18. journal 2006;145:582-91. 102 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13836 A Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding Aerobic Exercise in Treating Dysmennorrhoea among Adolescent Girls, Haldwani, Uttarakhand
Neha joshi1, Babita Bisht2, Sonu Khanka2 1Nursing Tutor. Graphic Era Hill University, 2Nursing Tutor Graphic Era Hill University
Abstract Dysmennorrhoea is a common problem in women of reproductive age, is a very serious problem that can often directly effect the quality of life and cause periodic college absenteeism. Primary dysmennorrhoea or painful menstruation without pelvic pathology is one of the most common complaints in women’s medicine and Secondary dysmennorrhoea is pain that is caused by a disorder or any infection in the woman’s reproductive organs. Aerobic exercise is commonly cited as a probable remedy for menstrual symptoms with limited research available. The purpose of the study was to observe the effect of aerobic exercise on primary dysmennorrhoea.
Material and Methodology:- A quantitative research approach with Pre-Experimental design with one group pre-test and post-test was used. The study was conducted in Haldwani, Uttarakhand. The convenient sampling techniques were used to select the study subjects. Date was collected from 40 adolescent girls by using structured knowledge questionnaire.
Result:- The pre-test was taken by using structured knowledge questionnaire designed by researcher and administered structured teaching programme on same day. After 7 days post test was taken. The data was analyzed by using frequency, percentage, mean, standard deviation was used to describe the result. Inferential statistics like paired t test, Chi square test. The overall mean pre-test knowledge score of adolescent girls was 0.322± 24.27 and mean post-test knowledge score of adolescent girls was 0.634± 46.902 and the mean difference was 0.312. The ‘t’ value was 12.177.Hence the scores predicted that the significant difference between the mean pre-test and post-test at p<0.05 level. This revealed that the structured teaching programme was effective in improving adolescent girl’s knowledge on effectiveness of aerobic exercise in treating dysmennorrhoea.
Conclusion:-From this study the researcher found that the adolescent girls have gained knowledge regarding aerobic exercise. The result of this study showed there is an improvement of knowledge regarding aerobic exercise in treating dysmennorrhoea after given structured teaching programme.
Keywords: - Primary dysmennorrhoea, aerobic exercise, dysmennorrhoea, adolescent girls, knowledge, structured teaching programme, effectiveness,
Introduction menarche1.
The period of adolescence is transition from Adolescent is a phase of changeover from childhood childhood to adult life along with pubertal development to adulthood. For a girl, adolescent is a blend of physical and sexual maturation. During puberty, hormonal, and psychological preparation to enroll into a safe psychological, cognitive and physical changes occur motherhood. Naturally, menstruation is mentioned to simultaneously. One of the major physiological changes be that significant physiological change that welcomes that take place in adolescent girls is the onset of adolescent girls into her reproductive stage. 2 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 103
When adolescent girls are ovulatory cycles, primary Aerobic Exercise today is an integral part of normal dysmennorrhoea begins during the teenage years, and life for many women. It is clear that there are many its prevalence increases and then decreases with age health benefits for women who exercise regularly and spread. In primary dysmennorrhoea pain and started in moderation. Exercise improves cardiovascular status, bleeding a few hours before it takes 72-12 hours. The increased bone mineral content; improve dysmennorrhoea symptoms can include nausea, vomiting secondary and premenstrual syndrome symptoms.1 to pain, diarrhea, and rarely. The cause of primary MATERIAL AND METHODS dysmennorrhoea, severe uterine contractions due to the secretion of prostaglandin F2 is the endometrium during The Quantitative approach and Pre-experimental 3 the menstrual cycle. design with one group pre-test – post-test design was used. Non- probability purposive sampling technique Dysmennorrhoea is defined as difficult menstrual was used to collect the 40 Adolescent girls. The study flow or painful menstruation. The term dysmennorrhoea was conducted Girls Inter College Haldwani. The is derived from the Greek Word Dys meaning difficult/ Adolescent girls who were willing to participate in the painful/abnorma” Meno meaning month and rhoea study, present at the time of data collection and able to meaning flow. Dysmennorrhoea is a Gynecological understand and speak Hindi language were included in medical condition characterized by serve uterine pain the study. The investigator had collected the data after during menstruation4. getting permission from the authority from Haldwani Dysmennorrhoea is the most common gynecologic (Uttarakhand). And approval was obtained to conduct the complaint among adolescent females. It is usually study. The participants were informed about the purpose primary, and is associated with normal ovulatory cycles of the study and written consent was taken from the and with no pelvic pathology.5 participants. Pre-test was done by using Demographic Performa and knowledge questionnaire. Structured Primary dysmennorrhoea or painful menstruation Teaching Program (STP) was implemented after pre- without pelvic pathology is one of the most test. Post test was conducted seven days after pre-test. common complaints in women’s medicine. Primary Descriptive statistics includes frequency, percentage, dysmennorrhoea can affect the quality of life of women6. mean, standard deviation was used to describe the result. The American College of Sports Medicine (ACSM) Inferential statistics like paired t test, Chi square test, defines aerobic exercise as any activity that uses large were used to find the effectiveness and association. muscle groups, can be maintained continuously and is rhythmic in nature7.
Findings Table-1 Frequency and percentage distribution of the socio demographic characteristics of the adolescent gi rls. n =40 S.no. Variables Frequency (f) Percentage% Age in years- 13-14 years 1 2% 1. 14-19 years 0 0% 15-16 years 12 30% Above 16 year 27 68%
Religion- Hindu 38 95% 2. Muslim 2 5% Christian 0 0% Others 0 0% 104 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Cont... Table no-1: frequency and percentage distribution of the socio demographic characteristics of adolescent girls.
Age at menarche- 10-11 years 2 5% 3. 11-12 years 9 22% 12-14 years 11 28% Above 14 years 18 45%
Onset of dysmenorrhea- First menarche onwards 14 35% 4. Within an year after menarche 8 20% After 1 year 8 20% After 2 or more years 10 25%
Family income per month- Less than 5,000 30 75% 5. 5,000 to 10,000 4 10% 10,000 to 15,000 5 13% More than 15,000 1 2%
Bleeding characteristics- Only blood 21 53% 6. Blood with clot 15 38% Thick blood 3 7% Thin blood 1 2% Occupation of father- Farmer 16 40% 7. Government employee 7 18% Private employee 16 40% Business person 1 2% Number of days of menstruation- Less than 3 days 5 13% 8. 3-4 days 22 55% 5-6 days 12 30% More than 6 days 1 2%
Social status of family- Upper class 0 0% 9. Middle class 32 80% Lower class 3 8% Below poverty line 5 12% Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 105
Figure no:1 Pre-test level of knowledge of adolescent girls regarding aerobic exercise in treating dysmennorrhoea. n =40
Figure 1 Shows that in pre-test the adolescent girls having (55%), Poor knowledge,(45%) having Average knowledge and (0%) is having good knowledge regarding aerobic exercise in treating dysmennorrhoea.
Figure-2 Post -test level of knowledge of adolescent girls regarding aerobic exercise in treating dysmennorrhoea. n =40
Figure 2: Shows that in post-test the adolescent girls having (2%), Poor knowledge,(68%) having Average knowledge and (30%) is having good knowledge regarding aerobic exercise in treating dysmennorrhoea. That means after giving structured teaching programme the adolescent girls having improving her knowledge regarding aerobic exercise in treating dysmennorrhoea. 106 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Figure 3: Comparison of pre-test and post-test knowledge of adolescent girls regarding aerobic exercise in treating dysmennorrhoea. n =40
Figure 3:Shows that comparison of pre-test and post-test knowledge of adolescent girls. It include 3 categories, majority of the adolescent t girls were having poor knowledge regarding aerobic exercise in treating dysmennorrhoea before implementing structured teaching programme. After implementing teaching module majority of the adolescent girls were having average or good knowledge regarding aerobic exercise in treating dysmennorrhoea. Hence it can show that after administered structured teaching programme the knowledge is increased of adolescent girls regarding aerobic exercise in treating dysmennorrhoea .
Table-2 Comparison of Mean, Mean percentage value of Pre-test and post-test on knowledge of aerobic exercise in treating dysmennorrhoea among adolescent girls. n =40
Post-test Pre-test Mean Pre-test Mean% Post-test Mean% Mean Knowledge score
0.322 0.634 32.2% 63.4%
Table-2 Shows that comparison of pre-test mean, mean percentage and post-test mean, mean percentage. The pre-test mean (0.322) and mean percentage is (32.2%) and post-test mean (0.634) and mean percentage (63.4%). Hence it can show that post test mean percentage is increased than pre-test mean percentage. That mean after given structured teaching programme the knowledge of adolescent girls regarding aerobic exercise in treating dysmennorrhoea is increased.
Table-3 Comparison of mean difference of pre-test knowledge and post knowledge score on adolescent girls regarding aerobic exercise in treating dysmennorrhoea. n =40
Pre-test Post-test Mean difference ‘t’ value P value Mean±SD Mean±SD Knowledge socre
0.322±24.27 0.634±46.902 0.312 12.177 2.04
Df39=2.04 at p<0.05 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 107
Table-3 The findings shows that the mean of post- adolescent girls before structured teaching programme. test knowledge score(0.634±46.902) of the adolescent The pre-test Mean was 0.322, Mean% was 32.2% girls was higher than that of pre-test knowledge score and SD was 24.2784 (0.322±24.27) and the mean difference was 0.312 paired t-test was performed to compare the mean of pre-test Ø To evaluate the knowledge on effect of aerobic and post-test knowledge score. The t calculated value exercise on primary dysmennorrhoea after structured (12.177) was higher than the tabulated value. Hence the teaching programme. scores predicted that the significant difference between the mean of pre-test and post-test at p<0.05 level. Hence The post-test Mean was 0.634,Mean% was 63.4% the null hypothesis was rejected and research hypothesis and SD was 46.9028 .The paired ‘t’ test value was was accepted. This significant improvement in the 12.17798. knowledge can be the intervention. To determine the association between the Discussion knowledge on effectiveness of aerobic exercise primary dysmennorrhoea and selected demographic variables. In the present study significant difference between the mean of pre-test and post-test score and t calculated The association of demographic data shows that value was higher than tabulated value. That indicate the knowledge of adolescent girls was not influenced by structured teaching programmed was effective method socio-demographic variables except the significant to improve the knowledge of adolescent girls regarding variables i.e age of adolescent girls, age at menarche and aerobic exercise in treating dysmennorrhoea. family income. Per month.
Description of personal characteristics of This study also supported by Nategheh adolescent girls. Dehghanzadeh, Ebrahim Khoshnam* and Asghar Nikseresht. These study findings reveled that eight In the present study,majority 68%of adolescent weeks aerobic exercise reduces sympathetic activity girls are in age of above 16 years. This study was and increases blood flow to the uterus and increase the supported by Soni.T.K;,G.Sumathi also stated the secretion of endorphins, physical and psychological familiar findings that the majority of adolescent girls symptoms of primary dysmennorrhoea is lowered. 2 were between the age group of (18-20 years.) significant difference between pre-test and post-test This study was also supported by Shabnam knowledge was found (t =27.94, p<0.05). Which indicate Omidvar Majority of adolescent girls were between that educational programmed has been an effective the age group of (16-19 years.)8 method of increasing the knowledge of the mothers.
In the present study, majority (95%) of This study also supported by Mrs.Nimmy Augustine, adolescent girls in Hindu family. This study supported Mrs. Sudha Maheswari, Sr. Jacintha D’Souza .These by Shabnam Omidvar Majority of the participants study findings reveled the mean percentage of post test (80.2%) belonged to the families practicing Hinduism.8 dysmennorrhoea score (54.58) was lower than the pre test score (83.87) in the experimental group which was In the present study 35% of the adolescent girls significant at 0.05 level. The statistical analysis showed were having onset of dysmennorrhoea from first a significant reduction in the severity of dysmennorrhoea menarche onwards. In the present study supported by among adolescent girls in the experimental group after Mrs.Zahra Mohebbi Dehnavi also stated that 40% of the the introduction of aerobic exercises (t14=19.21). The‘t’ adolescent girls have onset of dysmennorrhoea from the value computed between the experimental and control first menarche onwards.6 group after the intervention was statistically significant at 0.05 level. (t28=12.06). Objectives:- This study also supported by Anuradha Sutar, Sayli Ø To assess the pretest knowledge on effect of Paldhikar, Nigar Shikalgar, Snehal Ghodey. These study aerobic exercise on primary dysmennorrhoea among 108 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
findings reveled that the results showed that pain (VAS on Januarary 2020] scores) in the exercise group declined significantly. The 2- Soni.T.K, Sumathi.G.Aerobic Exercise: To trim VAS scores started to decrease just after the beginning down menstrual distress among adolescent girls of the exercise intervention and continued to decrease Dec-2014;3(4):374-381[Available from www. in the subsequent three visits and was statistically ijrpp.com][Cited on Januarary 2020] significant (p<0.05). 3- Dehghanzadeh N, Khoshnam E, Nikseresht A. The effect of 8 weeks of aerobic training on primary This study also supported by Soni.T.K,G.Sumathi dysmenorrhea 2014 ;4(1): 380-382 [Available These study findings showed that the mean score of from www.pelagiaresearchlibrary.com][Cited on menstrual distress after aerobic exercise were (62.63) Januarary 2020] in posttest1(on the 2nd menstrual day) and(40.77) in Pathania P A study to evaluate the effectiveness of th 4- posttest2 (on 5 menstrual day) which was lesser than structured teaching programme on dysmenorrhea the score aerobic exercise (84.10). This Cleary signifies in terms of knowledge among the GNM students a decreased in menstrual distress among adolescent girls of Shimla Nursing College2018; 4(3): 429-433 with dysmennorrhoea. [Available from www.allresearchjournal.com ] [Cited on Januarary 2020] Conclusion 5- Augustine N, Maheswari S, D’Souza J The Based on the findings of the study, it is concluded Effect of Aerobic Exercises on Reduction of that most of the adolescent girls had good knowledge Dysmennorrhoea among Adolescent Girls regarding aerobic exercise to treating dysmennorrhoea 2018 ;1(4) [Available from http://mbnc.edu.in/ after implementation of Structured Teaching Programme. UTUJAHI.html ][Cited on Januarary 2020] So structured teaching programme was effective for 6- Dehnavi Mohebbi Z, Jafarnejad F, Kamali Z improving the knowledge of adolescent girls aerobic The Effect of aerobic exercise on Primary exercise to treating dysmennorrhoea. dysmennorrhoea 2018; [Available from www. pelagiaresearchlibrary.com][Cited on Januarary Source of Funding-Self Funded 2020] Patel H, Alkhawam H, Madanieh R, Shah N, Ethical Clearance: No Ethical Issue 7- Kosmas C, VittorioT Aerobic vs anaerobic exercise Conflict Clearance: There is no conflict of interest training effects on the cardiovascular system2017; exit 9(2): 134–13[Cited on Januarary 2020] 8- Omidvar.S, Nasiri Amiri.F, Bakhtiari.A, and References Begum.K A study on menstruation of Indian 1- Sutar A, Paldhikar S, Shikalgar N, Ghodey S. Effect adolescent girls in an urban area of South India of aerobic exercises on primary dysmennorrhoea 2018 Jul-Aug; 7(4): 698–702.[Available from in college students Sep. - Oct. 2016; 5( 5): 20-24 https://www.ncbi.nlm.nih.gov/pmc/articles/ [Available from www.iosrjournals.org 20][Cited PMC6132001/][Cited on Januarary 2 DOI Number: 10.37506/ijphrd.v12i1.13837 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 109 Dynamics of Utilization of Modern Contraception by the Females of Slums of Noida
Nidhi Pundhir1, Arindam Das2 1Director, HCL Foundation, Ph D Scholar, IIHMR University, Jaipur, 2 Associate Professor, IIHMR University, Jaipur
Abstract Unplanned urbanisation has led to a significant rise in number of slums in metro cities of India. Gautam Buddh Nagar District, of Uttar Pradesh, is no exception. Family planning indicators remain dismally poor amongst the habitants, pushing them further into poverty. HCL Foundation in partnership with FPAI conducted a study “My Choice, My Right”: Enabling urban slum based communities including young people in Noida to lead better lives by choosing Family Planning. We used the study data to find out the dynamics of utilization of contraceptives in slums of Noida. A total of 735 women, in reproductive age group, were interviewed during the study. Only 53 percent were found to have knowledge regarding contraception. Only one-fourth (26 percent) of the overall respondents ever used any modern contraception method in the study area. Majority (91 percent) used either female sterilization (41 percent) or male condoms (37 percent) or OCP (13 percent). Policy makers, decision makers and implementors must consider level of awareness on contraception and use of modern methods as two critical factors while designing policy and intervention plans for this segment of population.
Keywords: Family Planning, Contraception, Women, Empowerment, SDG 5, Urban, Slums.
Introduction family and society.1 It should ensure safe and healthy sex life by using a collection of preventive methods As urbanization continues to persist in India, the and techniques. In 1951, India was the first country to wellbeing of the urban poor, whose majority live in slum launch National Family Welfare program (NFWP). settlements will increasingly drive national development Over the decades, the NFWP has seen a paradigm shift indicators including SDGs and FP2020 goals. Most of from population control to integrated approach with the the health indicators of urban slums are even worse than National Rural Health Mission (NRHM). With NRHM, that of rural areas. It is therefore central to understand there was an integrated approach adopted applying both and identify ways to address the poor reproductive health and demographic specific indicators under NFWP. health outcomes among poor urban slum populations in The revised goals not only aim at population control, it the country. also includes protection of reproductive rights of women, Reproductive health presents a lifelong continuous to reduce Maternal Mortality Rate (MMR) and Infant process associated with various stages of women in the Mortality Rate (IMR) by increasing availability and accessibility towards modern contraceptive methods. Contraceptive usage and family planning correlates Corresponding Author’s Details: highly with the indicators maternal and child health. Ms. Nidhi Pundhir According to Sample Registration System (SRS) 2016 Director, HCL Foundation - 18 MMR in India has reduced from 130 per 1,00,000 Corporate Towers, HCL Technology Hub, live births to 113 per 1,00,000 livebirths. Total fertility Plot No 3A ,Sector 126, Noida - 201303. UP (India) has reduced from 2.7 (NFHS 3, 2005-06) to 2.2 (NFHS Phone: +91-9891555975; +91 120 430600 4 2015-16). IMR has reduced to 41 per 1000 live births e-mail: [email protected] (NFHS 4, 2015-16) from 57 per 1000 live births (NFHS 110 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
3, 2005-06).2-4 If the selected respondents were not present at home, 3 visits were made and after 3 visits, they were recorded Study Background as non-response. A total of 735 female respondents, in To understand the knowledge and utilization of reproductive age group, were interviewed during the modern contraceptive methods amongst the women of study. urban slums, HCL foundation has conducted a study ii. Techniques adopted for analysis: Univariate, namely “My Choice, My Right”: Enabling urban slum bi-variate, and multivariate techniques were used to based communities including young people in Noida analyze the data. Statistical test like chi-square test was to lead better lives by choosing Family Planning. We conducted to find the association between respondents’ used the data to find out the dynamics of utilization of characteristics and their knowledge and present contraceptives in slums of Noida. Noida houses a large utilization of modern family planning methods. Also, population of income poor and vulnerable people, living binary logit regression was used to find the determinants in compromised conditions of housing and sanitation in of modern family planning method use. the urban slums, with less than optimal access to health services including family planning. The urban slums Results and Discussion tend to be ever expanding due to the influx of migrants Analysis was carried out to find socio-economic in search of a living, piling on, mostly from parts of UP, and demographic characteristics of the respondents. Bihar and West Bengal. The existing health, education, Results of the same suggests, most of the respondents water, and sanitation facilities are not designed to reach (88 percent) were Hindu, one-third (36 percent) were this unchecked, unplanned growing population. illiterate, and two-third (68 percent) were homemaker. Objectives Nearly 68 percent got married at or after reaching the legal age for marriage. More than half (55 percent) · Find out the knowledge and utilization of respondents reported their age as more than 30 years and modern contraceptive amongst respondents 41 percent found having more than two children (3 and · Study the dynamics of utilization of modern above). contraceptive in the females residing in slums of Noida Further, the analysis reveals, a little more than half (53 percent) of them found having the knowledge Methodology regarding contraception. However, they mentioned i. Sampling technique: A Multi-stage cluster various source for this knowledge, namely, friends/ sampling technique was adapted for the selection of relatives/neighbours (63 percent), doctors (56 percent), the respondents. In the first stage, a complete house husband/partner (47 percent) and ASHA/health listing was conducted prior to the individual survey. worker (32 percent) amongst others. Most of them (85 In the second stage, the entire study area was divided percent) mentioned medical store as the source of the into clusters of approximately 500 households each contraception followed by hospital/clinic (73 percent). geographically. A total 120 such clusters formed. One- When the question regarding ever use of contraception third, i.e., 40 clusters were selected by systematic random was asked, it was found that around half (49 percent) of sampling. From these selected 40 clusters (Primary the respondents amongst who had knowledge regarding Sampling Units), households for individual survey were contraception ever used a method of contraception. It identified based on the number of years household head suggests around one-fourth (26 percent) of the overall is living in Noida, up to 5 years (migrant) and above respondents ever used any modern contraception (non-migrant). From the selected households in each method in the study area. Information was also collected PSU, 20 women in the age group 15-49 years were to find what method they used, it was emerged out that selected using random sampling technique. Household the majority (91 percent) used either female sterilization heads staying less than 6 months were excluded from (41 percent) or male condoms (37 percent) or OCP the sample selection for individual survey. Within each (13 percent). However, current uses of contraception household, only one person was selected for interview. amongst respondents suggest, 47 percent found using Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 111 female sterilization, 35 percent male condoms and nearly 12 percent reported using oral contraception pills on the day of interview.
Additionally, analysis was done to find out the association between characteristics of the respondents with knowledge of contraception. Results of the same are being presented in Table 1.
Table 1: Association Between Characteristics and Knowledge Regarding Modern Contraception (N = 389)
Characteristics Number Value of Chi Square Test
Education*
Illiterate 112
Primary 21
Middle 49 30.763 Secondary 126
Higher Secondary 40
Graduate and above 41
Religion*
Hindu 354 9.348 Others 35
Caste
Scheduled Caste (SC) 69
Scheduled Tribe (ST) 32 2.900 Other Backward Class (OBC) 165
Others 123
Occupation*
Homemaker 282 7.140 Working 107
Husbands’ Education*
Illiterate 57
Primary 22
Middle 50 38.204 Secondary 152
Higher Secondary 67
Graduate and above 41 112 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Cont... Table 1: Association Between Characteristics and Knowledge Regarding Modern Contraception (N = 389)
Husbands’ Occupation*
Not Working 17 6.774 Working 372
Standard of Living Index (SLI)*
Low 141
Medium 201 31.431
High 47
Age of the Respondents*
15-19 7
20-29 160 52.154
30 & above 221
Age at Marriage (respondent)
<18 132 1.902 >=18 257
Marital Status*
Currently Married 380 7.824 Others 9 45.645 Husband living with Respondent* 369
Children ever born*
No child 46
1-2 children 182 54.581 3-4 children 136
5 & more children 25 0.216 Pregnancy not resulted in live births 53
* p<0.05 As mentioned in methodology section, further, the The analysis suggests that characteristics namely, research tries to find out the association between the religion, education, education of husband, occupation of characteristics of the respondents with their current use self and husband, standard of living index, age of the of modern contraception. Chi-square test was performed respondents, her marital status, children ever born and to see whether any statistically significant association whether husband is living with the respondent or not between these variables were present or not. The results emerged out having statistically significant association are presented in Table 2. with knowledge regarding family planning. (Table 1) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 113
Table 2: Association Between Characteristics and Current Use of Modern Contraception (N =164) Characteristics Number Value of Chi Square Test Education* Illiterate 44 Primary 5 Middle 26 15.837 Secondary 60 Higher Secondary 16 Graduate and above 13 Religion* Hindu 154 7.944 Others 10 Caste* Scheduled Caste (SC) 26 Scheduled Tribe (ST) 20 10.222 Other Backward Class (OBC) 64 Others 54 Occupation* Homemaker 128 9.506 Working 36 Husbands’ Education* Illiterate 27 Primary 5 Middle 18 33.586 Secondary 69 Higher Secondary 30 Graduate and above 15 Husbands’ Occupation* Not Working 5 21.063 Working 159 Standard of Living Index (SLI)* Low 51 Medium 88 23.251 High 25 Age of the Respondents* 15-19 5 20-29 52 20.692 30 & above 106 Age at Marriage (respondent)* <18 67 8.168 >=18 97 Marital Status* Currently Married 159 27.239 Others 5 Husband living with Respondent* 159 26.069 114 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Cont... Table 2: Association Between Characteristics and Current Use of Modern Contraception (N =164)
Children ever born* No child 5 1-2 children 72 47.137 3-4 children 75 5 & more children 12 Pregnancy not resulted in live births 22 0.104
* p<0.05
The analysis suggests that respondents’ characteristics namely, religion, caste, education of respondents, education of husband, occupation of self and husband, standard of living index, age of the respondents, her marital status, age at marriage, children ever born and whether husband is living with the respondent or not found having statistically significant association with current use regarding modern family planning. (Table 2)
To find out the determinants of current utilization of modern family planning, binary logit regression was done with dependant variable current use of modern family planning =1 and non-using of modern family planning currently = 0. The characteristics of the respondents were used as predictors. The results of the binary logit regression are being presented in Table 3.
Table 3: Determinants of Utilization of Modern Contraceptive methods Characteristics Exp (B) CI lower bound CI Upper bound Education# IlliterateR Primary 2.683 0.967 7.446 Middle 2.677 0.738 9.707 Secondary 1.327 0.468 3.768 Higher Secondary 1.849 0.337 2.136 Graduate and above 1.184 0.451 3.117 Religion# HinduR Others 0.393 0.193 0.798 Caste* Scheduled Caste (SC)R Scheduled Tribe (ST) 1.001 0.553 1.811 Other Backward Class (OBC) 1.335 0.657 1.925 Others 1.867 1.175 2.968 Occupation HomemakerR Working 0.776 0.491 1.226 Husbands’ Education IlliterateR Primary 0.543 0.197 1.499 Middle 1.348 0.367 4.952 Secondary 0.849 0.307 2.35 Higher Secondary 0.662 0.274 1.598 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 115
Cont... Table 3: Determinants of Utilization of Modern Contraceptive methods
Graduate and above 0.671 0.279 1.615 Husbands’ Occupation Not WorkingR Working 1.333 0.472 3.762 Standard of Living Index (SLI)* LowR Medium 3.131 1.535 6.384 High 2.251 1.141 4.437 Age of the Respondents* 15-19R 20-29 1.727 0.978 3.658 30 & above 1.126 0.704 1.802 Age at Marriage (respondent)# <18R >=18 1.737 0.699 4.127 Children ever born* No childR 1-2 children 8.377 2.298 13.539 3-4 children 0.774 0.356 1.679 5 & more children 0.532 0.256 1.107
* p<0.05, # p<0.10, R = Reference category
The analysis suggests that as education increases OBC women, women having higher economic status the utilization of modern contraception also increases and 1-2 children. While policymakers and practitioners (p<0.1). It was also found that respondents followed designing the policy and intervention plan the factors other religion utilizing 0.61 times lesser modern method listed in the study should be considered. of contraception while comparing with Hindu women. Further, the analysis shows, respondents from other caste Ethical Consideration and OBC found utilized more than their Scheduled Caste Respondents participated voluntarily in this study. counterparts (p<0.05). Respondents found having 1-2 Informed consent was taken. Interviews were conducted children utilized modern contraception 8.38 times more in Hindi. All data kept secure, password protected, and than the women who did not have any child. Contrary privacy of respondents ensured. At the end of interview, to that females reported 3-4 children and more than that they were provided with information on modern family found utilizing modern contraception less (Table 3). planning methods.
Conclusion and Suggestions Acknowledgement: We sincerely acknowledge The study suggests poor utilization of modern time given by all respondents, diligence of all surveyors, contraception amongst the females residing in slums efforts of the FPAI team and the HCLF team, who were of Noida. By and large only one-fourth (26 percent) involved in the study. amongst the respondents found utilizing any modern Source of Funding: The study and the consecutive contraception during the survey. Utilization of project is fully funded by HCL Foundation. contraception was more amongst educated women, women following Hinduism, women of other caste and Conflict of Interest: Nil 116 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
References Available from: http://www.censusindia.gov.in/ vital_statistics/SRS_Reports_2018.html 1. Arindam Das, Sivaraman S, Kailash Prajapati. Contraception Use: Does Socio Economic Factors 3. SRS Statistical Report 2016. India: Registrar Matter in Maharashtra, India? An Investigation General and Census Commissioner; 2016. through NFHS-4 Data. Indian Journal of Available from: http://www.censusindia.gov.in/ Public Health Research & Development. 2019 vital_statistics/SRS_Reports_2016.html May;10(5):745-750. 4. National Family Health Survey (NFHS-4), 2015- 2. SRS Statistical Report 2018. India: Registrar 16: India. Mumbai: International Institute of General and Census Commissioner; 2018. Population Sciences (IIPS) and ICF; 2017. DOI Number: 10.37506/ijphrd.v12i1.13838 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 117 Socio-Economic Determinants of Maternal Health Care Payments among Women in India
R. Vivekanandhan1, A.K. Ravishankar2 1Research scholar, Department of population Studies, Annamalai University Annamalai Nagar, Tamil Nadu, India - , 2Associate Professor, Department of Population Studies, Annamalai University Annamalai Nagar, Tamil Nadu, India
Abstract Background: Government of India initiatives through implementation of National Rural Health Mission (NRHM) and Janani Suraksha Yojna (JSY) programs from early 2005 has shown a considerable impact on maternal health care utilization in India. Despite the fact that these programs provide the services free of cost, utilization of maternal health care services is still considered an economic burden on some households. Keeping this into our mind, the research study analyzes the different level of payments to procure maternal health care for different socio-economic characteristics in India.
Materials and Methods: This paper has utilized the data collected by the National Sample Survey Organization (NSSO) during January -June, 2014. It is a cross sectional dataset that provides information on Social Consumption and Health scenario of the population. To carry out the research, descriptive statistics, and regression analysis has been used.
Findings and Conclusion: The research reveals that women residing at urban place of residence, higher educated, affiliated to other social group and belonging to richest wealth index pay high amount for the maternal healthcare services in India. Indian government need to extend the coverage rendering the services at affordable costs without any further differentiation on the basis of socio-economic characteristics of Indian women.
Keywords: Ante-natal care, Healthcare payments, Maternal health care, Post natal care.
Introduction on maternal health care utilization in India1. These programs has well defined goal to provide accessible, Majority of the women experience complications affordable and quality healthcare to the rural population, during their pregnancy, delivery, and post delivery especially the vulnerable groups. Community Health that causes severe complexities and requires prompt volunteers like Accredited Social Health Activists obstetric care. Government of India initiatives through (ASHAs) and Auxiliary Nurse Midwives (ANMs) are implementation of National Rural Health Mission village-level female health workers in India who are in (NRHM) and Janani Suraksha Yojana (JSY) programs the direct contact with the population for facilitating from early 2005 has shown a considerable impact and providing healthcare services such as ANC care, diagnostic facilities, promoting institutional deliveries and other outpatient and inpatient care in the country2. Corresponding Author: R. Vivekanandhan, India is one of the rapidly developing countries Research scholar, Department of population Studies, where health is still a challenge at the national level, Annamalai University Annamalai Nagar, Tamil Nadu, although maternal and child health indicators have India - 608 002, shown a little progress. People living with poverty, [email protected] 118 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
accessibility, and unawareness are the major reasons for Moreover healthcare professionals and policymakers poor uptake of maternal health care services in India. For often overlook individual healthcare payments in example, in one the India’s poorest states, Bihar, where maternal health care services. We hypothesized that over 80 percent of births are home births, approximately although maternal health care services in India are 50 percent of women reported financial hardship as the offered free at the point of delivery, many households’ main reason for not utilizing the maternal health care3. bear excessive out of pocket expenditure. Our aim It is despite the fact that maternal health care services is to investigate deeper into the payments incurred are provided free-of-charge in public health facilities in in the utilization of maternal health care services (i.e. India. This sluggish progress in reducing maternal and antenatal care and postnatal care) for different socio- child mortality in India could be attributed to the various economic characteristics in India. This would help us factors as socioeconomic and regional inequality in the understand the economic burden of maternal health care availability, accessibility, and affordability of healthcare services (i.e. antenatal care and postnatal care) on Indian services4. households and quantify the levels of payments incurred with respect to different socio-economic characteristics. There are several research studies conducted that prove different factors which might influence the Materials and Methods utilization of maternal healthcare services utilization in This paper has used the data collected by the India. A research study from West Bengal showed that National Sample Survey Organization (NSSO) during the number of episodes of illness, type of medical care, January – June, 2014. This round provides data on chronic illness of a household member, Medical health Social Consumption and health. The dataset provides care costs, and hospitalization costs were important enough information related to the prevalence, nature of predictors of household healthcare payment5. So far, only treatment, level of care and financial expenditure for a little evidence on individual and household expenditure different morbidity in India. is available and that too is very limited across India. Only few supportive evidence could be found in particularly Descriptive statistics is used to provide simple Western and Southern India where the utilization summaries about the sample and also about the 6 of maternal healthcare services . A research study observations that have been made. It is used to show also analyzed maternal health care expenditure using the prevalence of maternal health care with respect to 7 national level data of Indian households . However, different socio-economic characteristics. To find out this study did not consider the different costs associated the odds of maternal health care payments for different with maternal health care expenditures, which could be socio-economic characteristics regression analysis has substantial especially for the poorest-poor seeking care been used in the study. In this study complete maternal in the public sector. health care comprises of women who has taken antenatal care and post-natal care.
Results and Discussion
Figure 1: Percentage distribution of payments for different maternal health care services utilization. Source: NSSO 71ST Round Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 119
The figure 1 depicts the payments incurred on women care services. Majority of the women have spent the for maternal health care services utilization in India. The amount that ranges from Rupees 0 to rupees 5 thousand payments for maternal health care (i.e. antenatal care to utilize the maternal health care services. Ninety three and post natal care) is categorized into different amount percent women have spent the amount that ranges from category that ranges from Rupees 0 to rupees 5k, from rupees 0 to rupees 5 thousand while 5 percent women 5k to 10k, and above 10k. Eighty percent of women spent the amount that ranges from rupees 5 thousand to spent amount that ranges from rupees 0 to rupees 5k in 10 thousand and only 2 percent women spent the amount the utilization of antenatal care services in India. Only above 10 thousand to utilize the post natal care services 14 percent of women spent amount that ranges from in India. Rupees 5 thousand to rupees 10 thousand while 6 percent women spent above 10 thousand to utilize the antenatal
Figure 2: Percentage distribution of payment for antenatal care services for different socio-economic characteristics. Source: NSSO 71ST Round 120 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
The figure 2 reveals the payment distribution of payment to utilize post natal care services decreases in antenatal care services for different socio-economic the range of rupees 0 to rupees 5 thousand. Older age characteristics. Fourteen percent women in the age group women spend higher amount than younger aged women 20 – 35 years spent the amount that ranges from rupees to receive postnatal care services in India. Four percent 5 thousand to rupees 10 thousand for the utilization of women above 35 years spend higher amount of rupees antenatal care services in India. With regards to the place above 10 thousand to receive postnatal care services of residence, urban women (8 percent) spent higher in India. With regards to the place of residence, urban amount that exceeds above rupees 10 thousand for the women (3 percent) spent higher amount that exceeds utilization of antenatal care services in India. Similarly, above 10 thousand for the utilization of postnatal care widowed/separated women (88 percent) spent the amount services in India. Similarly, currently married women that ranges from rupees 0 to rupees 5 thousand than show distinguishing amount variation in receiving the currently married and never married women. Although, postnatal care services in India than widowed/separated never married women (11 percent) spend high amount women. Six percent of never married women show high of above rupees 10 thousand than other counterparts. payment of above rupees 10 thousand to receive postnatal With regards to education, 16 percent higher educated care services in India. With regards to education, 5 women spent above rupees 10 thousand to receive percent higher educated women spent above rupees antenatal care services than secondary educated (6 10 thousand to receive postnatal care services than percent) and primary educated (3 percent). Scheduled secondary educated (2 percent) and primary educated (1 tribe women (91 percent) spent high amount that ranges percent). Payment for postnatal care services increases from rupees 0 to rupees 5 thousand to receive antenatal with the increase of education standard among women care services. Women affiliated with other social group in India. Scheduled tribe women (96 percent) spend high category (7 percent) spent the high amount of above amount that ranges from rupees 0 to rupees 5 thousand rupees 10 thousand to utilize the antenatal care services to receive postnatal care services. Women affiliated than scheduled castes and scheduled tribes. Four percent with other social group category (2 percent) spend the women affiliated with Islam religion spend the amount high amount of above rupees 10 thousand to utilize of above rupees 10 thousand to utilize the antenatal care the postnatal care services than scheduled castes and services which is lower than the women affiliated with scheduled tribes. Three percent women affiliated with Hindu (6 percent) and other religion (6 percent). With Islam religion spend the amount of above rupees 10 respect to the wealth index, 14 percent women belonging thousand to utilize the postnatal care services which is to the richest wealth index spend high amount of rupees higher than the women affiliated with Hindu (2 percent) above 10 thousand to utilize the antenatal care services and other religion (2 percent). With respect to the wealth followed by the richer (5 percent), rich (4 percent), poor index, 4 percent women belonging to the richest wealth (3 percent) and poorest (2 percent). Ninety two percent index spend high amount of rupees above 10 thousand women belonging to poorest wealth index spend the to utilize the postnatal care services followed by the amount that ranges from rupees 0 to rupees 5 thousand richer (2 percent), rich (1.6 percent), poor (1.2 percent) to receive the ante-natal care services in India. and poorest (1 percent). Ninety six percent women belonging to poorest wealth index spend the amount that The figure 3 represents the payment distribution ranges from rupees 0 to rupees 5 thousand to receive the of postnatal care services for different socio-economic postnatal care services in India. characteristics. With the increase of age, women Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 121
Figure 3: Percentage distribution of payment for postnatal care services for different socio-economic characteristics. Source: NSSO 71ST Round 122 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table1: Odds ratio of maternal health care payments for different socio-economic characteristics.
Antenatal care payments Postnatal care payments
O.R Confidence Interval O.R Confidence Interval
Age group
Below 20®
20-25grp 0.81 **(0.74-0.89) 0.97 (0.88-1.07)
26-30grp 0.80 ***(0.74-0.88) 1.23 **(0.93-1.14)
31-35grp 0.81 **(0.73-0.89) 1.06 (0.95-1.18)
Above35 0.72 *(0.64-0.82) 1.06 (0.92-1.21)
Sector
Rural ®
Urban 1.26 ***(1.01-1.10) 0.99 (0.95-1.03)
Marital status
Not married ®
currently married 0.66 *(0.38-1.12) 0.87 *(0.51-1.48)
widowed/separated 0.56 (0.31-1.03) 0.94 (0.51-1.73)
Education
Primary®
Secondary 1.35 **(1.29-1.41) 1.29 ***(1.23-1.35)
Higher 1.80 **(1.69-1.90) 1.60 ***(1.50-1.70)
Social group
Scheduled tribe ®
Scheduled caste 1.32 (1.23-1.42) 1.20 ***(1.11-1.29)
others 1.56 **(1.46-1.66) 1.33 ***(1.24-1.42)
Religion
Hindu®
Islam 1.02 (0.96-1.07) 1.06 (1.00-1.12)
Others 1.04 (0.97-1.12) 1.07 (0.99-1.15)
Wealth Index
Poorest®
Poor 1.22 **(1.15-1.30) 1.10 **(1.03-1.18)
Middle 1.43 **(1.35-1.52) 1.18 **(1.11-1.25)
Richer 1.62 **(1.52-1.72) 1.31 **(1.23-1.40)
Richest 2.20 ***(2.06-2.35) 1.50 ***(1.40-1.60)
_cons 987.5 (887.05-1245.85) 747.3 (546.07-1021.87)
Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 123
*sig. at 10% level; **sig. at 5% level; ***sig. at 1% to richest wealth index pay higher for the utilization of level; ® Reference category maternal health care services in India. Majority of the women pay for the utilization of antenatal care services (Source: NSSO 71st Round). but do not utilize the postnatal care. Indian government The table 1 represents the odds ratio of maternal need to extend the coverage rendering the services at health care payments for different socio-economic affordable costs without any further differentiation on characteristics. Women in the age group 26-30 years the basis of socio-economic characteristics. are 80 percent more likely to have antenatal payment Conflict of Interest – None than women below 20 years of age. Women in the urban sector are 1.2 times more likely to pay for antenatal care Source of Funding – None than women residing in rural areas. Currently married Ethical Clearance – Secondary dataset, Available women are 66 percent more likely to go for antenatal in public domain. care than not married and widowed/separated women. Secondary and higher educated women are 1.3 and References 1.8 times more likely to have antenatal care treatment than women belonging to primary educated women. 1. Rai SK, Dasgupta R, Das MK, Singh S, Devi R, Similarly, women affiliated to other social group Arora NK. Determinants of utilization of services category are 1.5 times more likely to go for antenatal under MMJSSA scheme in Jharkhand’Client Perspective’: a qualitative study in a low performing care expenditure than women belonging to scheduled state of India. Indian journal of public health. 2011 tribe. Women belonging to richest wealth index are Oct 1;55(4):252. 2.2 times more likely to have antenatal care payment 2. Srinivasan K, Shekhar C, Arokiasamy P. Reviewing followed by richer (1.6 times), middle (1.4 times), poor reproductive and child health programmes in India. (1.2 times) than the poorest wealth index. Economic and Political Weekly. 2007 Jul 14:2931- It also reveals that women in the 26-30 age group 9. is 1.2 times more likely to go for postnatal care than 3. O’Donnell O, Van Doorslaer E, Rannan-Eliya women belonging to the age group of below 20 years. RP, Somanathan A, Adhikari SR, Harbianto D, Currently married women are 87 percent more likely to Garg CC, Hanvoravongchai P, Huq MN, Karan receive postnatal care services than not married women. A, Leung GM. The incidence of public spending Secondary and higher educated women are 1.3 and 1.6 on healthcare: comparative evidence from Asia. times more likely to pay for postnatal care services The World Bank Economic Review. 2007 Jan 1;21(1):93-123. than primary educated women. Women affiliated with scheduled castes and other social groups are 1.2 and 4. Peters DH, Yazbeck AS, Sharma RR, Ramana GN, 1.3 times more likely to pay for postnatal care services Pritchett LH, Wagstaff A. Better health systems for than women belonging to scheduled tribe. With regards India’s poor: findings, analysis, and options. The World Bank; 2002 May 1. to wealth index, richest wealth index is 1.5 times more likely to pay for post natal care services followed by 5. Goldie SJ, Sweet S, Carvalho N, Natchu UC, Hu D. richer (1.3 times), middle (1.2 times) and poor (1.1 Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis. PLoS Med. times) than the poorest wealth index. 2010 Apr 20;7(4):e1000264. Conclusion 6. Mavalankar D, Vora K, Prakasamma M. Achieving millennium development goal 5: is India serious?. Despite the government efforts to provide free 7. Bonu S, Bhushan I, Rani M, Anderson I. Incidence delivery of maternal health care services in India, the and correlates of ‘catastrophic’maternal health care reception of maternal health care services is still a expenditure in India. Health policy and planning. burden on Indian households. The research reveals that 2009 Nov 1;24(6):445-56. women residing at urban places affiliated to other social group, above 20 age group, higher educated and belong 124 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13839 A Comparative Study to Evaluate the Marginal Fit and Fracture Resistance of Peek Material with two Other Restorative Crowns Fabricated Using Cad – Cam Technology – An In Vitro Study
Rajevandra Jayesh2, P. Praveen1 1Post graduate Student, Department of Prosthodontics, Sree Balaji Dental College and Hospital, Chennai, 2Professor, Department of Prosthodontics, Sree Balaji Dental College and Hospital, Chennai
Abstract Aim : To compare and evaluate the marginal fit and fracture resistance of PEEK material with two other restorative crowns namely – DMLS (metal-ceramic – cobalt-chromium) & All ceramic
Materials and methods: 35 artificial crownsn were fabricated. 20 samples were earmarked for evaluation of marginal fit using stereomicroscope and 15 samples were intended for fracture resistance. Materials used for fabrication of crowns were metal ceramic, all-ceramic, and PEEK materials
Results : There was no statistically significant difference between these materials (P > 0.05). than fracture resistances were compared.
Conclusion : The marginal fit of all ceramic-zirconia crowns was higher than that of the PEEK and DMLS- metal-ceramic crowns and Fracture resistance of DMLS - metal-ceramic crowns was higher than the fracture resistance of the PEEK and all-ceramic- zirconia restorative crowns.
Keywords; PEEK, DMLS, Zirconia, Marginal fit, Fracture resistance.
Introduction Direct metal laser sintering is a computer-aided design (CAD)computer-aided manufacturing (CAM)- Commensurate with innovative techniques and the based technique, in which metal substructure can be dextrous skills of the prosthodontist, introduction of designed and fabricated using Co–Cr. It is a powder- new materials in dentistry paves the way for advanced based additive manufacturing method in which each prosthodontics treatment1.Fixed dental prostheses substructure is built up in a series of successive thin (FDPs) are the treatment of choice after endodontic and layers of 20– 60μm. operative treatments, all over the world2. Many alloys have been used in dentistry for fixed partial dentures From an esthetic standpoint, the metallic in teeth replacement based on their strength, longevity, frameworks, sometimes limit their use in the esthetically castability, and biocompatibility. visible areas even with the porcelain veneers. Quest for a more esthetic restorative material has been satisfied by all-ceramic restorations. Advantages of all-ceramics over metal-ceramics include color resemblance of the Corresponding author: teeth and translucency of zirconia similar to enamel3. Dr. Rajevandra Jayesh MDS In contrast to ceramics, Polyetheretherketone Professor, Department of Prosthodontics, Sree Balaji (PEEK), new material has been introduced in the Dental College and Hospital, Chennai dental field, purportedly exhibiting minimal shrinkage. Email – [email protected] Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 125
Polyetheretherketone (PEEK) is a sulfonated aromatic occlusal reduction, and functional cusp bevelling, high- temperature thermoplastic material. It belongs to whereas, all-ceramic restoration had 1.5 to 2mm the family of polyaryletherketone and its basic formula buccolingual reduction and 2mm occlusal reduction. (-C6 H4 -OC6 H4 -O-C6 H4 -CO-) n4. In 1978 it was 5 impressions of the mandibular full-arch were made developed by a group of English scientists. Later PEEK with dentulous perforated L4 metal tray using Zhermack was commercialized for industrial applications1 Elite HD+ soft putty and Zhermack Elite HD+ normal set light body, with double mix technique. Impressions In 1992, PEEK was used for dental applications, fi rst were poured using type IV dental stone. Restorative in the form of aesthetic abutments and later as implants. crowns were designed and fabricated using CAD-CAM Subsequently many variations in composition of PEEK technology. have helped enhance the working characteristics of the implant. It is highly inert, hence very resistant to chemical erosion5. It exhibits bone-like fl exibility and withstands high temperature6. Since this material has been a newly introduced one in prosthodontics, a need for evaluation of the marginal fi t of crowns fabricated with this material was felt necessary and hence this study was undertaken.
Aim The aim of the present study is to compare and evaluate the marginal fi t and fracture resistance of PEEK material with two other restorative crowns namely – Three restorative materials were selected among DMLS (metal-ceramic) and All ceramic which,
Objectives Group A – DMLS(metal ceramic) To compare the marginal fi t of PEEK crowns with Group B – Zirconia(All ceramic) two other restorative crowns namely – DMLS (metal- Group C – PEEK ceramic) & All-ceramic crowns Marginal fi t evaluation – steps To compare the fracture resistance of PEEK crowns with fracture resistance of two other restorative crowns 1. Die cut preparation namely – DMLS (metal-ceramic) & All-ceramic crowns 2. Restorative crowns cementation Materials and Method 3. Marginal fi t evaluation 35 artifi cial crowns, were fabricated. 20 samples were earmarked for evaluation of marginal fi t and 15 1. Die cut preparation samples were intended for fracture resistance. Materials Once casts were obtained from the impressions, they used for fabrication of crowns were metal ceramic, all- were subjected to Die-cut for evaluation of marginal fi t ceramic, and PEEK materials. in 36 and 46 regions. The die cuts were done using a saw Conventional tooth preparation was done in frame with a thin blade. mandibular 36 and 46 in typhodont model (fi g 1). Deep 2. Restorative crown cementation chamfer fi nish line was given in 36 region for DMLS - metal-ceramic restoration. Shoulder fi nish line was After die-cutting, the fabricated restorative crowns given in 46 region for all-ceramic restoration. For metal- namely (DMLS – metal ceramic, all-ceramic - zirconia ceramic restoration, the tooth preparation in 36 region and PEEK) were cemented on the cast using 3M ESPE yielded 1 – 1.5 mm buccolingual reduction, 1.5mm RelyXTM U200 resin cement with fi nger pressure. 126 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
3. Marginal fit evaluation
Cemented prostheses were examined using a stereomicroscope in a non-destructive method to evaluate the marginal fit on minimum four surfaces of each cemented crown (i.e.) buccal, lingual. mesial, distal (fig. 2-5). The obtained values were noted and compared with the values obtained from two other restorative crowns.
STEREOMICROSCOPIC EVALUATION OF MARGINAL FIT
Fig. 5 Buccal surface of PEEK crown in 36 Fracture resistance evaluation – steps
1. Metal die fabrication
2. Restorative crowns cementation
3. Fracture resistance evaluation (fig. 6)
Fig. 2 Buccal surface of zirconia crown in 46 1. Metal die fabrication
For standardization, dies were fabricated in metal using cobalt chromium alloy. Each die was mounted on a two-inch diameter metal ring using type IV die stone for better stabilization.
2. Restorative crowns cementation
After metal die stabilization, fabricated restorative crowns were cemented on the die using 3M ESPE RelyXTM U200 resin cement with finger pressure.
3. Fracture resistance evaluation Fig. 3 Buccal surface of zirconia crown in 46 Cemented prosthesis was placed under the universal testing machine. A 4 mm diameter metal ball (load applicator) with a bar was fixed in the universal testing machine. The load force applicator’s ball established three-point contact with the slopes of the vestibular cusps. Each cemented prosthesis was compressed until fractured by the UTS. After fracture, values were recorded in Newtons (N). Data obtained were tabulated and analyzed using student t-test and ANOVA test.
Fig. 4 Buccal surface of PEEK crown in 46 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 127
Results Stereomicroscope evaluation of the marginal fit of three types of restorative crown materials showed that there was no statistically significant difference between materials (P > 0.05). Table 1,2,3 and 4 show the marginal fit of different types of restorative crown materials. Comparison of fracture resistance of three restorative crown materials showed that there was a statistically significant difference between materials (P < 0.05). Table 5, shows the fracture resistance of three different types of restorative crowns.
MARGINAL FIT EVALUATION
Examined crown surfaces Serial no Buccal Lingual Mesial Distal
1 47.65 µm 39.25 µm 56.65 µm 73.60 µm
2 36.50 µm 42.65 µm 32.25 µm 67.04 µm
3 20.05 µm 35.05 µm 32.65 µm 25.15 µm
4 40.62 µm 34.60 µm 39.25 µm 64.26 µm
5 70.60 µm 63.05 µm 57.65 µm 39.20 µm
Table 1. shows stereomicroscope evaluation of marginal fit of zirconia crowns in 46
Examined crown surfaces Serial no Buccal Lingual Mesial Distal
1 112.86 µm 107.19 µm 73.60 µm 124.00 µm
2 73.60 µm 106.70 µm 82.20 µm 117.70 µm
3 88.80 µm 64.75 µm 118.46 µm 112.86 µm
4 44.45 µm 78.51 µm 53.95 µm 36.00 µm
5 171.74 µm 45.40 µm 98.14 µm 126.74 µm 128 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 2. shows stereomicroscope evaluation of marginal fit of DMLS (metal ceramic) crowns in 36
Examined crown surfaces Serial no Buccal Lingual Mesial Distal
1 55.76 µm 73.60 µm 93.14 µm 43.85 µm
2 45.39 µm 92.23 µm 40.64 µm 51.65 µm
3 78.57 µm 57.65 µm 55.15 µm 88.32µm
4 44.41 µm 39.25 µm 117.00 µm 98.14 µm
5 39.25 µm 45.40 µm 73.60 µm 83.42 µm
Table 3. shows stereomicroscope evaluation of marginal fit of PEEK crowns in 46
Examined crown surfaces Serial no Buccal Lingual Mesial Distal
1 94.85 µm 49.02 µm 78.66 µm 73.60 µm
2 98.14 µm 73.60 µm 71.74 µm 73.60 µm
3 77.28 µm 122.67 µm 93.23 µm 78.51µm
4 85.66 µm 103.04 µm 63.79 µm 78.51 µm
5 68.69 µm 98.65 µm 61.33 µm 102.48 µm
Table 4. shows stereomicroscope evaluation of marginal fit of PEEK crowns in 36 FRACTURE RESISTANCE OF THREE DIFFERENT TYPES OF CROWNS.
Fracture resistance of different types of restorative crowns expressed in kN Serial no Metal ceramic Zirconia PEEK
1 6.62 2.67 3.24
2 4.33 2.23 2.92
3 5.40 2.60 3.12
4 5.80 2.21 4.57
5 4.63 2.80 4.30
Table 5. shows fracture resistance of three different types of restorative crowns namely – DMLS (metal ceramic), Zirconia and PEEK crowns Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 129
Discussion obtained from the buccal, lingual, mesial and distal surfaces of PEEK in 36 were 84.924 µm, 89.40 µm, In fixed prosthodontic treatment, the quest for an 73.75 µm, and 81.34 µm respectively. ideal restorative material that can mimic different shades of the human dentition and simultaneously be able to Fracture Resistance cumulatively withstand the masticatory loads without fatigue has been a utopia for prosthodontists. The mean values of fracture resistance obtained from DMLS - metal ceramic, zirconia and PEEK crowns Conventionally, many alloys have been used to were 5.36kN, 3.63kN and 2.5kN respectively. There is serve mastication satisfactorily, ever since Dr William. a statistically significant difference between the groups. H. Taggart invented the lost wax process in dentistry in 1907. Although the function of mastication was The results reveal that effectively served with such alloys, the show of metallic 1. the mean fracture resistance value of DMLS color limited their usage to posterior segments of the was 5.36kN dental arch. 2. the mean fracture resistance value of PEEK was Ceramo metal crown gained popularity since it 3.63kN obtains a natural appearance of porcelain and the strength from the alloy component. Nevertheless, inadequate 3. the mean fracture resistance value of zirconia translucency and the opacity of the alloy substructure led was 2.5kN to the development of metal-free alternatives. Maximum marginal gap (91.88 µm) was exhibited The dire need for more natural mimicking and by DMLS crowns indicating that this material showed strong restorations and also allergenicity of alloys paved the least marginal fit. PEEK crowns with deep chamfer the way for the introduction of zirconium. showed a more marginal gap than the PEEK crowns with the shoulder finish line, suggesting that PEEK Zirconium, to a great extent, brought a renaissance to crowns when fabricated with shoulder finish line, can dentistry with the monolithic and layered variations; still, have a better marginal fit. Zirconia crowns exhibited the long term studies on the ability of zirconia to withstand least marginal gap of 45.53 µm, suggesting that zirconia occlusal forces without compromising on esthetics are crows have the best marginal fit. yet to be obtained. Zirconia is a polycrystalline ceramic without a glassy phase and exists in several temperature- PEEK material seems to be a promising one as it dependent forms. It has excellent mechanical properties has more fracture resistance than zirconia and possesses which make it more popular than other ceramics used in marginal fit in the clinically acceptable range. Itis dentistry7. resistant to wear and is physically and chemically stable. It is resistant to acid attacks except for sulphuric acid. Marginal Fit It remains stable and unchanged in the sterilization The mean (SD) values of marginal fit were obtained process. It has good biocompatibility both in-vitro and from the buccal, lingual, mesial and distal surfaces of in-vivo. Its low solubility and low reactivity make it a zirconia in 46 were 43.08µm, 42.92 µm, 42.92 µm good choice to use in patients with a history of allergies. and 52.23 µm, whereas the values obtained from the They are also amenable to the CAD-CAM process. They buccal, lingual, mesial and distal surfaces of PEEK in are radiolucent and it can be helpful for MRI patients as 46 were 52.676 µm, 61.63 µm, 61.63 µm, and 73.08 µm it will lead to less artifact formation. respectively. The present study used vertical loading for fracture The mean (SD) values of marginal fit were obtained resistance. The teeth were prepared according to clinical from the buccal, lingual, mesial and distal surfaces of guidelines and acceptable clinical dimensions. Adhesive DMLS - metal-ceramic crowns in 36 were 101.07 µm, resin cement was used since it is commonly used in 80.51 µm, 85.27 µm, and 100.68 µm, whereas the values clinical practice nowadays. Two different finish lines were used for samples of PEEK material, as (a) it is a new 130 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
material in the market (b) it was felt necessary to know 4. Tabasum S, Shetty P, Goutam M. Review Article which finish lines provide better marginal adaptations SNEAK PEEK INTO PEEK POLYMER : AN Although the clinical environment cannot be simulated INNOVATION. 2018;4(March). in an in-vitro study, the results of the present study can 5. Razzaque A, Dhaded S. An Insight into a Novel be extrapolated to clinical application with more number Material : PEEK. 2016;(June):1–6. of samples. 6. Josephson BA, Schulman A, Dunn ZA, Hurwitz W. A compressive strength study of an all-ceramic Conclusion crown. J Prosthet Dent. 1985;53(3):301–3. Within the limitations of the study, the following 7. Meirowitz A, Bitterman Y, Levy S, Mijiritsky E, conclusions were drawn Dolev E. An in vitro evaluation of marginal fit zirconia crowns fabricated by a CAD-CAM dental 1. Fracture resistance of DMLS - metal-ceramic laboratory and a milling center. BMC Oral Health. crowns was higher than the fracture resistance of the 2019 Jun 13;19(1). PEEK and all-ceramic- zirconia restorative crowns. 8. Park JY, Bae SY, Lee JJ, Kim JH, Kim HY, Kim WC. Evaluation of the marginal and internal gaps 2. The fracture resistance of PEEK restorative of three different dental prostheses: Comparison of crowns was higher than that of all ceramic- zirconia the silicone replica technique and threedimensional restorative crowns. superimposition analysis. J Adv Prosthodont. 3. The marginal fit of all ceramic-zirconia crowns 2017;9(3):159–69. was higher than that of the PEEK and DMLS- metal- 9. Yus EA, Cantarell JMA, Alonso AM. Comparison ceramic crowns of the marginal fit of milled yttrium stabilized zirconium dioxide crowns obtained by scanning 4. The marginal fit of PEEK restorative crowns silicone impressions and by scanning stone replicas. was higher than the DMLS- metal-ceramic crowns. J Adv Prosthodont. 2018;10(3):236–44. 10. Peek: properties and application as dental implant | Conflict of Interest – Nil International Journal of Recent Scientific Research Source of Funding – Self [Internet]. [cited 2019 Nov 14]. Available from: https://www.recentscientific.com/peek-properties- Ethical Clearance – SBDCH/IEC/04/2019/20 and-application-dental-implant. 11. Tekin S, Cangül S, Adıgüzel Ö, Değer Y. Areas for Reference: use of PEEK material in dentistry. Int Dent Res. 1. Gediminas Skirbutis, Agnė Dzingutė, Viltė 2018;8(2):84–92. Masiliūnaitė GŠ, Žilinskas J. A review of 12. Sinha N, Gupta N, Reddy K, Shastry Y. Versatility PEEK polymer ’ s properties and its use in of PEEK as a fixed partial denture framework. J prosthodontics. Rev Stomatol Balt Dent Maxillofac Indian Prosthodont Soc. 2017;17(1):80–3. J. 2017;19(1):19–23. 13. Bae SY, Park JY, Jeong I Do, Kim HY, Kim 2. Pompa G, Di Carlo S, De Angelis F, Cristalli JH, Kim WC. Three-dimensional analysis of MP, Annibali S. Comparison of Conventional marginal and internal fit of copings fabricated Methods and Laser-Assisted Rapid Prototyping with polyetherketoneketone (PEKK) and zirconia. for Manufacturing Fixed Dental Prostheses: An in J Prosthodont Res [Internet]. 2017;61(2):106– Vitro Study. Biomed Res Int. 2015;2015. 12. Available from: http://dx.doi.org/10.1016/j. 3. Manoharan PS, Rajasimhan NV, Livingstone D, jpor.2016.07.005 Arivarasan NK. Comparative analysis of fatigue 14. Ji S, Sun C, Zhao J, Liang F. Comparison and resistance, fracture strength, and fracture patterns analysis on mechanical property and machinability in ceramic crowns with zirconia and direct metal about polyetheretherketone and carbon-fibers laser-sintered cores - An in vitro study. J Adv Clin reinforced polyetheretherketone. Materials (Basel). Res Insights. 2018;5(4):92–8. 2015;8(7):4118–30. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 131
15. Najeeb S, Zafar MS, Khurshid Z, Siddiqui F. Res [Internet]. 2016;60(1):12–9. Available from: Applications of polyetheretherketone (PEEK) in http://dx.doi.org/10.1016/j.jpor.2015.10.001 oral implantology and prosthodontics. J Prosthodont 132 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13840 Orginal Article Prospective Study of Blunt Trauma Chest
Ram Gopal Sharma1, Piyush Kumar Sinha2, Rachith Sridhar3. , Nitesh Singh3, Duvaraha Devi C3 Arun Shankar V V3, Himanshu Tanwar3 1Professor, Dept. of Surgery, MMIMSR Mullana Ambala, 2Assistant Professor, Dept. of surgery, Dept. of surgery, MMIMSR, Mullana Ambala, 3Junior Resident, Dept. of surgery, MMIMSR, Mullana Ambala
Abstract Introduction: Trauma is a major cause of morbidity and mortality in both developed and developing countries. Globally 10% of all trauma admissions results from chest injury and 25% of trauma related deaths are attributed to chest injuries. Chest trauma may present as isolated injury or as a part of polytrauma.
Aim & Objectives: To study the clinical profile of cases with blunt trauma chest in reference to mode of injury, hospital stay, diagnosis, severity of injury, treatment offered morbidity and mortality.
Material & Methods: A prospective, observational, clinical study was conducted at Department of Surgery, MMIMSR, Mullana, and Ambala. Consecutive type of non-probability sampling was used for the selection of study subjects during study duration. A total of 50 consecutive cases fulfilling the eligibility criteria were taken for study after informed consent. Data was collected from these patients admitted in surgical wards and ICU. All the patients admitted with provisional diagnosis of blunt trauma chest were admitted in surgical ward/ ICU. Data was analyzed using statistical software SPSS vesion 21.
Results: As per injury severity score, low to medium severity injury was observed in 66% and 22% cases respectively. Severe injury was seen in 12% cases. As per injury severity score, low to medium severity injury was observed in 66% and 22% cases respectively. Severe injury was seen in 12% cases. Conservative management was sufficient in 36% cases while remaining cases required surgical intervention. Tube thoracotomy was required in 62% while mechanical ventilation was seen in 36% cases. Laparotomy was required in 20% cases. Pneumonia developed in 10% cases while pyothorax and septicaemia was seen in 4% and 8% cases respectively. Acute renal failure and Multi-organ dysfunction was seen in 1 case each. Increased injury severity score was associated with poly-trauma patients (p<0.01). Mean hospital and ICU stay was more in polytrauma cases as compared to isolated chest trauma cases (p<0.05). Incidence of Mortality was 4% in present study.
Conclusion: Blunt trauma chest is more common among the young males. Increased outdoor activities and vehicular
Key Words: - Blunt Trauma, Laprotomy, Tube Thoractomy, Pyothorax, Septicemia
Introduction report on road safety, RTAs would be the fifth leading cause of death worldwide by the year 2030[2]. Trauma represents a major epidemic of non- communicable disease in present century. They are no Globally 10% of all trauma admissions results longer considered accidental but are part of the price we from chest injury and 25% of trauma related deaths pay for the technological progress[1]. Trauma is a major are attributed to chest injuries [4, 5]. It is a major cause of morbidity and mortality in both developed and problem for India, also due to a very high incidence of developing countries. The usual causes are road traffic vehicular accidents (6% of global vehicular accidents), accidents (RTAs), fall from height, occupational injuries, other accidental injuries, crime and violence. In India and assault. According to the World Health Organization approximately 16000 deaths per year alone are a result Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 133
of chest trauma Sample Size: Consecutive type of non-probability sampling was used for the selection of study subjects [6] . during study duration. A total of 50 consecutive cases According to the National Trauma Database fulfilling the eligibility criteria were taken for study after (NTDB)[12], chest injuries are present in 13.8% of all informed consent. blunt trauma patients. The overall mortality rate of chest Study Duration: Oct 2016 - April 2018 trauma is 8.4%. The mortality rate of blunt thoracic trauma ranges from 9.5%-47.5%, depending upon the Inclusion Criteria severity of injury sustained. The most common cause All the adult patients of more than 18 years of is motor vehicular accident (MVA), followed by fall. age presenting with Blunt Trauma Chest admitted in MVAs account for 70-80% of such injuries. Emergency or OPD. Blunt thoracic trauma is often associated with Exclusion Criteria injuries to other organs, especially the abdominal solid organs as the upper part of the abdomen is overlapped Patient with Head Injury would be excluded from by the thoracic cage. Optimal care of severely injured this study. patients requires a coordinated approach from the point of injury, through a hospital facility organised to cope Data Collection Procedure with the demands of looking after multisystem problems, Data was collected from these patients admitted to a rehabilitation structure that can return the patient in surgical wards and ICU. All the patients admitted to his or her maximum potential level of function within with provisional diagnosis of blunt trauma chest were society. Although sophisticated prehospital and trauma admitted in surgical ward/ ICU. centre systems have been shown to reduce the number Following investigations were done in all cases: of preventable deaths after trauma, maximum impact in reducing the burden of trauma must come from injury 1. Routine Hemogram. prevention strategies[13]. 2. Bleeding Time, Clotting Time, Blood Group. This study takes into account blunt trauma chest cases being admitted to our hospital and different 3. Chest X-Ray PA view, USG Abdomen, USG modalities of treatment being offered to them. Thorax.
Very few studies have been conducted to analyse 4. CT Chest and Abdomen wherever required. the magnitude and management of Blunt trauma chest A special note was made of patients with Rib fracture, in Indian scenario. This study is carried out to determine Hemothorax, Surgical Emphysema and so on. Injuries the epidemiology of the aetiology of chest trauma along of Clavicular, Sternal and Scapular Fracture were also with analysing the management scheme and outcome of noted down. Severe injuries to tracheobronchial tree, chest injuries in a tertiary care set up in a rural area. lungs and heart were noted down.
Methodology Management in the form of conservative, tube Study Setting: Department of Surgery, thoracostomy, incision for surgical emphysema, MMIMSR, Mullana, Ambala thoracotomy were studied and recorded in the proforma. Number of blood transfusion required, morbidity and Study Population: Cases of Blunt Trauma Chest mortality was noted down for every patient. coming to our hospital.
Study Design: A Prospective, observational, Clinical study 134 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Results Table 1 Distribution of study subjects as per mode of transport of patient to hospital
Mode of Transport of Patient to Hospital N %
Ambulance 17 34.0%
Police 6 12.0%
Personal 21 42.0%
Self 3 6.0%
Unknown 3 6.0%
Total 50 100%
Most of the cases reached hospital either by ambulance (34%) or personal conveyance (42%).
Table 2 Distribution of study subjects as per duration of Injury before admission (hrs)
Duration of Injury before admission(hrs) N % 0 to 2 12 24.0% 2 to 6 13 26.0% 6 to 12 6 12.0% 12 to 24 4 8.0% 24 to 48 6 12.0% 48 to 72 8 16.0% >72 1 2.0% Total 50 100%
In half of the cases, duration of injury was either less than 2 hours (24%) or between 2 to 6 hours
(26%).
Table 3 Distribution of study subjects as per pattern of trauma
Pattern of Trauma N %
Pre-hospital Care offered 34 68.0%
Referral 15 30.0%
Arrived From Accident site 20 40.0%
Delayed 15 30.0% Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 135
Table 3 Distribution of study subjects as per pattern of trauma
Assault 2 4.0%
Fall 17 34.0%
Mode of Injury Industrial 4 8.0%
RTA 27 54.0%
Accelerated 12 24.0% Pattern Decelerated 38 76.0%
Chest Trauma Only 32 64.0% Type of Injury Poly-trauma 18 36.0%
Pre-hospital care was offered in 68% cases while direct admission from injury site was seen in 40% cases. Mode of injury was road traffi c accident in 54% cases while it was fall in 34% cases. Decelerated injury was observed in 76% cases while polytrauma was seen in 36% cases.
Most common presenting symptom was chest pain (58%) followed by dyspnea (54%), abdominal pain (24%), nausea/vomiting (22%) and hemoptysis (12%).
Table 4 Distribution of study subjects as per Chest X-ray fi ndings
Chest X-Ray N %
Rib Fractures 29 58.0%
White opacifi cation 9 18.0%
Hemothorax 26 52.0%
Pneumo-thorax 13 26.0%
Pneumo-hemothorax 6 12.0%
Clavicle Fracture 8 16.0%
Scapula Fracture 3 6.0%
Associated rib fractures were seen in 58% cases while white opacifi cation s/o lung contusion and scapula- clavicular fracture was seen in 18% and 22% cases respectively. Hemothorax, pneumothorax and pneumo-hemothorax was seen in 52%, 26% and 12% cases respectively.
Table 5 Distribution of study subjects as per USG Thorax fi xation 136 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Emphysema was seen in 4% and 32% cases respectively. Table 6 Association of type of trauma and Injury Severity Score
Type of Trauma ISS Score Total Chest Trauma Poly-trauma
31 13 44 < 15 70.5% 29.5% 100.0%
1 5 6 >/= 15 16.7% 83.3% 100.0%
32 18 50 Total 64.0% 36.0% 100.0%
p- value <0.01
Increased injury severity score was associated with poly-trauma patients (p<0.01).
Figure 1: Right sided Pneumothorax with Rib Fracture
Figure 2: A Patient of Blunt Trauma Chest
Discussion adult males between the ages of 20 and 40 years i.e. the Trauma is usually considered as the main cause of very productive period of life. In present study too, mean mortality and morbidity in individuals between 1 to 44 age of the subjects with Blunt Trauma Chest was 33.32 years. Chest injuries are common reasons for emergency years with almost two third of cases belonging to 18-40 medical care. Most of the injuries are found among young years of age (64%). Male predominance was seen among Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 137 study cases with 74% males to 26% females. common etiological factor (114, 57.4%)
Demirhan R et al in their study of 501 cases of followed by fall (20.8%), assault (14.4%), industrial chest trauma, observed mean age as 32.2 years with accident (4.2%) and animal attack (3.2%). RTA was 87.5% male and 12.5% females. Mean age in the study also the most common mode of injury in the studies by Sirmali M et al. on 1417 cases of thoracic trauma by Basoglu et al. (62%), Segers P et al. (72.2%), Saaig was 43 years with 331 males to 217 females. Basoglu M et al. (72%), Kumar A et al. (78%), Kasbe PA et al. A et al. studied 521 patients of chest trauma with 399 (60%), Shah JV et al. (76%) Okonta AE et al. (74.6%) males, and 122 females, with average age of 42 years. and Alassal M et al. (66%). A similar study by Segers P et al. showed male: female The results observed by other authors regarding ratio of 2.9:1 with average age of admission of 41.1 incidence of polytrauma are as follows: Basoglu et al. years. In a study by Sanjay Datey et al, 216 patient of (33%), Esme H et al. (66%). chest trauma showed most cases from age group 21 to 30 years (31.95% , 69 of 216), with 174 males and 42 Clinical Presentation females. Saaiq M et al. studied 143 patient with chest trauma, 119(83%) males and 24 (17%) females with Most common presenting symptom was chest pain most common age group of 21 to 50 yrs. Esme H et (92%) followed by dyspnoea (82%), abdominal al. studied 141 patients with 102 (72.3%) males and pain (24%), nausea/vomiting (22%) and hemoptysis 39 (27.7%) females and mean age of 40 years. Kumar (12%). On general examination, abrasions, contusions BA et al. conducted a cross sectional study on 200 and hematoma was seen in 70%, 54% and 26% cases patients with various forms of chest injuries. Males were respectively. Paradoxical chest movements and CCT commonly affected than female with 4.5:1 ratio, with was seen in 22% and 90% cases. In the study by Datey mean age as 44.78 years. Kasbe PA et al. conducted a S et al, most common signs and symptoms comprised prospective observational study involving chest injury of pain and tenderness of chest wall (93.5%) and patients. A total of 150 chest injury patients were studied respiratory distress in 83.8%. Chest pain and respiratory out of 864 patients of chest injury during the said period. distress were the commonest presentation observed in Males outnumbered females by a ratio of 5:1. Their various other studies. ages ranged from 10 to 80 years (mean = 37.27 years). Okonta AE et al. conducted a prospective study for a Esme H et al. in their study observed hypotension in 4-year period at two tertiary hospitals in Nigeria. On 11.3% cases of chest trauma.
hundred and twenty-six (52.3%) of 241 patients Type of Injury had blunt chest injuries (BCI), the average age was 40.4 years with a range of 0.8-79 years. There were 104 Rib fractures were seen in 58% cases while white (82.5%) male with a ratio of 4.7:1. opacification (s/o lung contusion) and scapula- clavicular fracture was seen in 18% and 22% cases respectively. Mode of Injury Hemothorax, pneumothorax and Pneumo-hemothorax was seen in 52%, 26% and 12% cases respectively. As Mode of injury was road traffic accident in 54% per injury severity score, low to medium severity injury cases while it was fall in 34% cases. Decelerated injury was observed in 66% and 22% cases respectively. Severe was observed in 76% cases while polytrauma was seen injury was seen in 12% cases. in 36% cases. In a study by Sirmali M et al. on 1417 cases of In the study by Demirhan R et al., RTA (72%) was thoracic trauma showed 38.7% had rib fracture. In a most common causative factor and polytrauma was seen study by Sirmali M et al 38.7% cases had rib fracture in 37.5% of cases. Most common aetiology observed by followed by pneumothorax (37.2%), hemothorax Sirmali M et al. was RTA (330 cases) fall from height (26.8%), haemopneumothorax (122 cases), assault (54 cases) and industrial accidents (42 cases). In the study by Datey S et al., RTA was most (15.3%), pulmonary contusion (17.2%), flail chest 138 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
(5.8%) and surgical emphysema (2.2%). Basoglu et al. organ in the studies by Esme H et al., Ziegler DW et al., in a similar study observed following injuries: Multiple Kumar A et al., Kasbe PA et al. (11.97%) and Mohta M rib fracture was present in 56%, single rib fracture in et al. 24% and flail chest in 8.4%. Extra thoracic injuries Management was in 33.2% with the involvement of extremities at 41% and skull at 40%. Common injuries observed in Conservative management was sufficient in the study by Segers et al.were: rib fracture (n=133), 36% cases while remaining cases required surgical pulmonary contusion (n=110), pneumothorax (n=78) intervention. Tube thoracotomy was required in 62% and hemothorax (n=65). Datey S et al. observed 82.4% while mechanical ventilation was seen in 36% cases. cases of Blunt trauma chest with pneumothorax in Laparotomy was required in 20% cases. In the study 44.4%, haemopneumothorax in 18% and contusion by Demirhan R et al, management offered in 501 cases of lung in 17.6%. Musculoskeletal injury was present of chest trauma were Intercostal Tube Drainage in 332 in 58, head injury in 52 with abdominal and pelvic (58%), conservative in 185 (32.5%), thoracotomy in trauma in 19 patients. In the study by Saaig M et al. [109], rib fracture (74%) was the most common chest 41(7.1%) and mechanical ventilation in 14 (2.4%). injury. Ziegler DW et al. studied 7147 patients. Out In the study by Segers et al.most of cases were managed of which 711 patients had rib fractures, 274(32%) had with observation and/or Intercostal Tube Drainage hemothorax or pneumothorax, 187(26%) had a lung (52.4%) and/or mechanical ventilation (61.0%). A contusion. Commonest injury observed by Kumar et al. total of 10.2% patient required thoracotomy (n=19). were rib Fracture (78%) followed by hemothorax (60%) Main indications of thoracotomy were pulmonary and Pneumothorax (44%). In the study by Kasbe et al, laceration (n=5), rib fracture was the commonest type of chest injury aortic rupture (n=3) and diaphragmatic rupture followed by pneumothorax, 88% and 62% respectively. (n=3). In the study by Datey S et al., 25% cases needed In the study by Shah JV et al, of the 100 studied only conservative treatment while 162 (75%) needed patients, 64% had rib fractures, 17% had flail chest, surgical intervention with 159 patients requiring 12% had pneumothorax, 24% had hemothorax, and 5% Intercostal Tube Drainage. In the study by Saaig M et al, had haemopneumothorax and 24% had extrathoracic Intercostal Tube Drainage was done in 65 (45%) patient injury. Common injuries observed in the study by and mechanical ventilation was given in 17(11.88%) Sah S et al. were pneumothorax followed by isolated patients. In the study by Esme H et al., symptomatic multiple rib fracture, hemothorax, isolated single rib management was done in 76 (53.9%), Intercostal Tube fracture haemopneumothorax, flail chest, subcutaneous Drainage in 59(41.8%) and thoracotomy in 11(7.8%) emphysema, lung contusion, open pneumothorax and patient. In the study by Kumar A et al, overall 76 % tension pneumothorax. patients required tube thoracostomy and 24% patients Abdominal Injuries were managed conservatively.
Injury to intra-abdominal organs was seen in 22% Complications & outcome cases with liver being the most common organ involved Pneumonia developed in 10% cases while (10%) followed by spleen – 8%, renal – 2% and pancreas pyothorax and septicemia was seen in 4% and 8% cases -2%. respectively. In the study by Kumar et al, commonest associated Common complications observed in the study solid abdominal organ injury is Liver (16%) followed by by Segers et al. were pneumonia (38%) and Acute Spleen (8%). Associated injuries in the study by Okonta Respiratory Distress Syndrome (7.0%). Pneumonia as AE et al. were extremities 25 (19.8%), cranio-spinal the commonest complication is also observed by Esme injuries in 10% cases while internal echoes and surgical H et al, Kumar A et al. [120], Kasbe PA et al. (11.97%) 17(13.5%) and blunt abdominal injuries13 (10.3%). and Mohta M et al. (9%). Liver is the most common affected intra- abdominal Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 139
Mortality rates observed in the studies by various Ashwin Lazarus, Mohan Gadodia, Mohit Gupta. authors is as follows: Demirhan R et al. (6.8%), Sirmali “Study of Clinical Profile and Outcome of 216 M et al. (5.7%), Basoglu et al. (7.1%). Victims of Chest Trauma in Tertiary Care Centre of Central India.” Journal of Evolution of Medical CONCLUSION and Dental Sciences 2015; 4(93): 43-47.
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Ravi Pachori1, Jiratithigan Sillapasuwan2, Shakeel A. Qidwai3 1Associate professor, Community Medicine Department, Hind Institute of Medical Sciences (HIMS), Sitapur, U.P. India, 2Lecturer, Department of Mental Health & psychiatric, College of Nursing, Rajabhat university, Pibulsongkram, Thailand, 3Principal, Hind Institute of medical Sciences (HIMS), Sitapur, U.P. India
Abstract Introduction: Most of lifestyle choices are related to various risk factors for non-communicable diseases, such as diet patterns, physical inactivity, tobacco and alcohol consumption etc. Objective: To assess the dietary, addiction habits and physical activity of medical and nursing students of HIMS Sitapur, and to determination of differences exist by gender. Methodology: A cross-sectional study was carried out in December 2019 among medical and nursing students of HIMS, Sitapur. A total of 820 students which included 496 males and 324 females participated in the study. A Structured, self-administered and pretested questionnaire was prepared for lifestyle risk factors. Data collected were compiled in MS Excel software and analysed in institutional SPSS version 22. Result: Majority students 503 (61.3%) prefer vegetarian diet highly significant but Fruit and vegetable consumption were occasional among most of 304 (37.1%) students. Alcohol consumption was found 201 (32.5%) in all students, habit of smoking is present in 66 (8.0%) students, tobacco chewing is very less common only in 25 (3.0%) students and significantly 328 (40.0%) students were not engaged in any kind of physical activities. Conclusion: Health education and its reinforcement especially in the area of alcohol consumption, tobacco chewing, smoking and physical activity is required.
Keywords: Alcohol, Tobacco, Smoking, Physical Activity
Introduction deaths from NCDs and 23% Probability of premature A lifestyle disease is defined as a Noncommunicable mortality from NCDs in India. They continue to be diseases (NCDs), such as cardiovascular diseases, an important public health challenge in all countries, cancer, diabetes and chronic respiratory diseases, are the including low- and middle-income countries where 1 leading global cause of death and are responsible for just more than three quarters of NCD deaths occur. The over 70% of deaths worldwide. These NCDs share key importance of adolescence also lies in the fact that this modifiable risk factors like tobacco use, unhealthy diet, age group has their root causes many serious diseases lack of physical activity, and the harmful use of alcohol, in adulthood. Growing period, maturation and unique which in turn lead to overweight and obesity, raised changes are occurred significantly in adolescence and blood pressure, and raised cholesterol, and ultimately many adult patterns are established during this period, diseases which are responsible for 63% Percentage of therefore adolescence is the appropriate time period for appropriate intervention.2,3 Teenagers start making individual choice and develop personal lifestyles which Corresponding Author: is highly susceptible for adopting unhealthy behaviour Dr. Ravi Pachori, at individuals’ level in young age and these unhealthy Associate Professor, Community Medicine behaviours very difficult to modify at later ages or after Department, Hind Institute of Medical Sciences the onset of disease.4 The objective of this study was to (HIMS), Sitapur, U.P. India, Mob.7000050719, assess the dietary, addiction habits and physical activity Email:[email protected] to following a healthy lifestyle of medical and nursing Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 143 students of HIMS Sitapur, and to determination of salty 151 (18.4%). Fruit and vegetable consumption differences exist by gender. were occasional among most of 304 (37.1%) students followed by 1-3 servings/week in 258 (31.5%) students Material and Methods and only 151 (18.4%) students consumed fruits and This cross-sectional study was carried out in vegetable on a regular basis. 147 (17.9%) students used December 2019 among medical and nursing students added table salt and 352 (42.9%) students used added of Hind institute of medical sciences Sitapur, Uttar ghee/butter in their diet respectively and around one Pradesh, India. A total of 820 students which included third students skipped breakfast in the morning. Table-2 496 males and 324 females participated in the study. All show that overall alcohol consumption was found 201 medical and nursing students aged 18 years, invited to (32.5%) in all students. It was more common in nursing participate in the study by way of notices on institution students 102 (42.9%) as compared to medical students notice boards and brochures distributed in lecture rooms 99 (17.0%) and it is more common in males 173 (34.9%) and who were present in the lecture theatre were enrolled as compared to females 28 (8.6%). Regarding initiation for study. All medical and nursing students who were of alcohol consumption most of the students 179 (89.0%) th eligible and consented to the study were included in the initiated alcohol consumption after 12 standards and th study. Informed consent was taken from each student remaining 22 (11.0%) before 12 standards. Majority and absentees, unwilling and those who were sick on of students 76 (37.8%) consumed an amount of 60 ml the day of data collection were excluded. Purpose of the or less at one time and around one third 66 (32.8%) study was explained to all medical and nursing students consumed one can beer at a time. Nearly one fourth and assured confidentiality of their responses. 24 (24.0%) medical students stated that they consumed more than 60 ml of alcohol in single sitting. Regarding A Structured, self-administered and pretested the frequency 177 (88.1%) and personal places 176 questionnaire was prepared for lifestyle risk factors (87.6%) for alcohol consumption had it occasionally which included dietary habits, Smoked and smokeless on private party. Table-3 depicts that the habit of tobacco used, alcohol consumption, physical activity. smoking is present in overall 66 (8.0%) students, being The questionnaire was pre-tested in few selected young more in nursing students 34 (14.3%) as compared to hospital staff. Vague terms, phrases and questions medical students 32 (5.5%). This habit was present in identified during the pre-test were modified, changed 66 (13.3%) males through none of the females smoked. and missing responses like no response and others were Majority 53 (80.3%) smoker learned after 12th standard added, with skipping patterns were also corrected. A and 13 (19.7%) learned it even prior to admission in 12th pre-tested restructured questionnaire was used as a tool standard. Majority 40 (60.6%) smoke 1-2 cigarette at a for the study and questionnaires were then administered time, occasionally 49 (74.2%) and personal places 60 to the selected medical and nursing students. Data (90.9%). Table-4 depicts that tobacco chewing is very collected were compiled in MS Excel software and less prevalent, only 25 (3.0%) students and that too only analysed in institutional SPSS version 22. Variables of among males 25 (5.0%). Almost three fifth of them lifestyle risk factors were analysed either by chi square 15 (60.0%) initiated tobacco chewing after admission or Fischer exact test, data was presented in percentages in college even though 10 (40.0%) had initiated even (%) and proportions form with statistical significance before finishing school. Only 15 (60.0%) tobacco user was considered at 0.05 level. students consumed it regularly and almost all consumed it personal places 23 (92.0%). Table-5 shows the nature Result of the physical activity and recreational used by medical Table-1 shows dietary habits of medical and and nursing students. For recreation nearly two third 533 nursing students. Majority students 503 (61.3%) prefer (65.0%) students preferred out campus activities over in vegetarian diet with a 3:1 ratio of veg & non-veg diet campus 287 (35.0%). Regarding physical activity 492 among medical & nearly 1:1 ratio in nursing students. (60.0%) students were engaged in either 320 (39.0%) Almost half of the students 402 (49.0%) had a liking weekly/occasionally or 172 (21.0%) daily physical for spicy food followed by sweet 240 (29.3%) and exercise of more than 30 minutes or exercises in gym, 144 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 but 328 (40.0%) students were not engaged in any kind of physical activities. Nearly one third 263 (32.1%) students preferred sports activities being lower in girls 62 (19.1%) whereas nearly one fourth 197 (24.0%) students preferred yoga. Tables
Table No: -1. Gender wise dietary habits in medical and nursing students
Variables Medical Nursing Gender Total 1. Type of diet students students Male Female n (%) n (%) n (%) n (%) n (%) Vegetarian 390 (67.9) 113 (45.4) 267 (53.8) 236 (72.8) 503 (61.3) Non-vegetarian 192 (32.1) 125 (54.6) 229 (46.2) 88 (27.2) 317 (38.7) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p<0.0001 p<0.0001 2. Personal liking of𝜒𝜒 2taste= 0 .1697 𝜒𝜒2 = 0.1916 Salty 111 (19.1) 40 (16.8) 59 (11.9) 92 (28.4) 151 (18.4) Sweety 179 (30.7) 61 (25.6) 129 (26.0) 111 (34.2) 240 (29.3) sour 22 (3.8) 5 (2.1) 22 (4.4) 5 (1.5) 27 (3.3) spicy 266 (46.4) 136 (55.5) 286 (57.7) 116 (35.9) 402 (49.0) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Chi square test , d.f.=3 , d.f.=3 p=0.0510 p<0.0001 3. Fruit and veg. consumption𝜒𝜒2 = 7.771 𝜒𝜒2 = 57.613 Occasional 214 (36.8) 90 (37.8) 193 (38.9) 111 (34.2) 304 (37.1) 1-3serving/week 183 (31.4) 75 (31.5) 149 (30.0) 109 (33.6) 258 (31.5) 4-6serving/week 80 (13.7) 27 (11.3) 67 (13.5) 40 (12.3) 107 (13.0) Regular 105 (18.0) 46 (19.3) 87 (17.6) 64 (19.9) 151 (18.4) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Chi square test , d.f.=3 , d.f.=3 p=0.8138 p=0.4443 4. Added salts 𝜒𝜒2 = 0.948 𝜒𝜒2 = 2.676 Yes 116 (19.9) 31 (13.0) 131 (26.4) 16 (4.9) 147 (17.9) No 466 (80.1) 207 (87.0) 365 (73.6) 308 (95.1) 673 (82.1) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p=0.0209 p<0.0001 5. Added ghee 𝜒𝜒2 = 0.09669 𝜒𝜒2 = 0.3488 Yes 239 (41.1) 113 (47.5) 227 (45.8) 125 (38.6) 352 (42.9) No 343 (58.9) 125 (52.5) 269 (54.2) 199 (61.4) 468 (57.1) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p=0.1026 p=0.0436 6. Habit of skip breakfast𝜒𝜒2 = 0 .05393 𝜒𝜒2 = 0.07010 Yes 192 (32.4) 78 (35.2) 183 (36.9) 87 (26.9) 270 (32.9) No 390 (67.5) 160 (64.8) 313 (63.1) 237 (73.1) 550 (67.1) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p=1.0000 p=0.0030 𝜒𝜒2 = 0.002020 𝜒𝜒2 = 0.1087
Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 145
Table No: -2. Gender wise alcohol consumption habit in medical and nursing students Alcohol Medical Nursing Gender Total 1. Intake students students Male Female n (%) n (%) n (%) n (%) n (%) Yes 99 (17.0) 102 (42.9) 173 (34.9) 28 (8.6) 201 (32.5) No 483 (83.0) 136 (57.1) 323 (65.1) 296 (91.4) 619 (67.5) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p<0.0001 p<0.0001 2. Initiation 𝜒𝜒2 = 0.2878 𝜒𝜒2 = 0.3389 Before 12th std. 14 (14.0) 8 (7.9) 17 (9.6) 5 (20.0) 22 (11.0) After 12th std 86 (86.0) 93 (92.1) 159 (90.4) 20 (80.0) 179 (89.0) Total 100 (100) 101 (100) 176 (100) 25 (100) 201 (100) Fisher’s Exact d.f.=1 , d.f.=1 Test p=0.1829 p=0.1621 3. Amount 𝜒𝜒2 = 0.15399 𝜒𝜒2 = 0.1155 Up to 60 ml 45 (45.0) 31 (30.6) 63 (35.8) 13 (52.0) 76 (37.8) >60 ml 24 (24.0) 35 (34.7) 54 (30.7) 5 (20.0) 59 (29.4) 1 Cane Beer 31 (31.0) 35 (34.7) 59 (33.5) 7 (28.0) 66 (32.8) Total 100 (100) 101 (100) 176 (100) 25 (100) 201 (100) Chi square test , d.f.=2 , d.f.=2 p=0.0877 p=0.2760 4. Frequency 𝜒𝜒2 = 4.867 𝜒𝜒2 = 2.575 Occasional/Party 89 (89.0) 88 (87.1) 157 (89.2) 20 (80.0) 177 (88.1) Regularly 11 (11.0) 13 (12.9) 19 (10.2) 5 (20.0) 24 (11.9) Total 100 (100) 101 (100) 176 (100) 25 (100) 201 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p=0.8481 p=0.3180 5. Site 𝜒𝜒2 = 0.0366 𝜒𝜒2 = 0.997 Privately 87 (87.0) 89 (88.1) 156 (88.6) 20 (80.0) 176 (87.6) publicly 13 (13.0) 12 (11.9) 20 (11.4) 5 (20.0) 25 (12.4) Total 100 (100) 101 (100) 176 (100) 25 (100) 201 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p=0.9788 p=0.3678 𝜒𝜒2 = 0.0007 𝜒𝜒2 = 0.8111
146 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table No: -3. Gender wise tobacco smoking habit in medical and nursing students Tobacco Medical Nursing Gender Total 1. Intake students students Male Female n (%) n (%) n (%) n (%) n (%) Yes 32 (5.5) 34 (14.3) 66 (13.3) 0 66 (8.0) No 550 (94.5) 204 (85.7) 430 (86.7) 324 (100) 754 (92.0) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 Not applicable Test p<0.0001 2. Initiation 𝜒𝜒2 = 0.2446 Before 12th std. 8 (26.7) 5 (13.9) 13 (19.7) 0 13 (19.7) After 12th std 22 (73.3) 31 (86.1) 53 (80.3) 0 53 (80.3) Total 30 (100) 36 (100) 66 (100) 0 66 (100) Fisher’s Exact , d.f.=1 Not applicable Test p=0.2266 3. Amount 𝜒𝜒2 = 0.2003 1-2 18 (60.0) 22 (61.1) 40 (60.6) 0 40 (60.6) 3-4 7 (23.3) 7 (19.4) 14 (21.2) 0 14 (21.2) >4 5 (16.7) 7 (19.4) 12 (18.2) 0 12 (18.2) Total 30 (100) 36 (100) 66 (100) 0 66 (100) Chi square test , d.f.=2 Not applicable p=0.9096 4. Frequency 𝜒𝜒2 = 0.1894 Occasionally 19 (63.3) 30 (83.3) 49 (74.2) 0 49 (74.2) Regularly 11 (39.7) 6 (16.7) 17 (25.8) 0 17 (25.8) Total 30 (100) 36 (100) 66 (100) 0 66 (100) Fisher’s Exact , d.f.=1 Not applicable Test p=0.0909 5. Site 𝜒𝜒2 = 0.2593 Privately 25 (83.3) 35 (97.2) 60 (90.9) 0 60 (90.9) publicly 5 (16.7) 1 (2.8) 6 (9.1) 0 6 (9.1) Total 30 (100) 36 (100) 66 (100) 0 66 (100)
Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 147
Table No: -4. Gender wise tobacco chewing habit in medical and nursing students Tobacco Medical Nursing Gender Total 1. Intake students students Male Female n (%) n (%) n (%) n (%) n (%) Yes 16 (2.7) 9 (3.8) 25 (5.0) 0 25 (3.0) No 566 (97.3) 229 (96.2) 471 (95.0) 324 (100) 795 (97.0) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 Not applicable Test p=0.5020 2. Initiation 𝜒𝜒2 = 0.07195 Before 12th std. 5 (33.3) 5 (50.0) 10 (40.0) 0 10 (40.0) After 12th std 10 (66.7) 5 (50.0) 15 (60.0) 0 15 (60.0) Total 15 (100) 10 (100) 25 (100) 0 25 (100) Fisher’s Exact , d.f.=1 Not applicable Test p=0.4422 3. Amount 𝜒𝜒2 = 0.1667 1-2 10 (66.7) 5 (50.0) 15 (60.0) 0 15 (60.0) >2 5 (33.3) 5 (50.0) 10 (40.0) 0 10 (40.0) Total 15 (100) 10 (100) 25 (100) 0 25 (100) Fisher’s Exact , d.f.=1 Not applicable Test p=0.4422 4. Frequency 𝜒𝜒2 = 0.1667 Occasionally 10 (66.7) 5 (50.0) 15 (60.0) 0 15 (60.0) Regularly 5 (33.3) 5(50.0) 10 (40.0) 0 10 (40.0) Total 15 (100) 10 (100) 25 (100) 0 25 (100) Fisher’s Exact , d.f.=1 Not applicable Test p=0.4422 5. Site 𝜒𝜒2 = 0.1667 Privately 14 (93.3) 9 (90.0) 23 (92.0) 0 23 (92.0) publicly 1 (6.3) 1 (10.0) 2 (8.0) 0 2 (8.0) Total 15 (100) 10 (100) 25 (100) 0 25 (100)
148 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table No: -5. Gender wise physical activity in medical and nursing students Medical Nursing Gender Total students students Male Female n (%) n (%) n (%) n (%) n (%) 2. Recreation In campus 263 (45.9) 24 (10.1) 157 (31.7) 130 (40.1) 287 (35.0) Out campus 319 (54.1) 214 (89.9) 339 (68.3) 194 (50.9) 533 (65.0) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p<0.0001 p=0.0136 2. Physical exercise/Gym𝜒𝜒2 = 0 .3179 𝜒𝜒2 = 0.08898 Daily 137 (23.5) 35 (14.7) 107 (21.6) 65 (20.1) 172 (21.0) 1-3day/week 131 (22.5) 33 (13.9) 96 (19.4) 68 (21.0) 164 (20.0) Weekly 130 (22.3) 26 (10.9) 94 (19.0) 62 (19.1) 156 (19.0) None 184 (31.7) 144 (60.5) 199 (40.0) 129 (39.8) 328 (40.0) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Chi square test , d.f.=3 , d.f.=3 p<0.0001 p=0.9227 3. Sport activity 𝜒𝜒2 = 59.403 𝜒𝜒2 = 0.4826 Yes 234 (40.2) 29 (12.9) 201 (40.5) 62 (19.1) 263 (32.1) No 348 (59.8) 209 (87.1) 295 (59.5) 262 (80.9) 557 (67.9) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p<0.0001 p<0.0001 4. Yoga 𝜒𝜒2 = 0.2650 𝜒𝜒2 = 0.2346 Yes 152 (60.0) 45 (60.0) 119 (60.0) 78 (60.0) 197 (24.0) No 430 (40.0) 193 (40.0) 377 (40.0) 246 (40.0) 623 (74.0) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100) Fisher’s Exact , d.f.=1 , d.f.=1 Test p=0.0306 p=1.0000 𝜒𝜒2 = 0.8136 𝜒𝜒2 = 0.001076
Discussion A. et.al. that 63.8% most of the respondents were non vegetarian.6,7 All students prefer more spicy food rather This study has found a marked unhealthy lifestyle than other foods and it has shown highly significant risk factors as dietary habits, less physical activity and in male as compared to females. Fruits and vegetables some addictions in medical and nursing students could are responsible for improving general health although be as a result of changes in lifestyle and increased present study has found lower consumption rate of urbanization. Preference for vegetarian diet than fruits and vegetables daily. The finding from present non-veg diet is shown highly significant in our study study correspond to study among the medical students might be result of Hindu religion promote vegetarian in New Delhi found, only 12% of students consumed diet. A similar proportion of respondents 53.4% were minimum 5 servings of fruits & vegetables daily and 5 vegetarians in Mahmood S.E. et.al. study. This is in similarly reported by Mehan MB. et. al. in their study contrast to the findings reported by the study conducted in which subjects had low daily intake of vegetables and in Maharashtra was 61.11% of the medical students were fruits.8 There was no significant difference in low fruits non-vegetarians and study documented by Srivastava Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 149
and vegetables consumption among medical and nursing Our findings related with smoking pattern among students, either for male or female. Nearly one fifth of medical and nursing students are almost same as reported students added extra salt to their cooked food items in by the previous study. Nearly 8% students had a smoking this study but comparatively nearly half of the students habit while 3% consumed tobacco in smokeless form in from a medical college in Delhi had a high salt intake our study whereas 14.1% respondents had a smoking by adding extra salt or by eating sauces and pickles and habit and 8.1% consumed tobacco in smokeless form in others study was reported by Rustagi N. et.al. 53.0%, and Mahmood SE. et.al study.5 Among the medical students by Mahmood SE. et.al 83.8%.2,5 Added ghee/butter was of New Delhi, only 7.0% of students used any form of found in present study more than two fifth of students tobacco which is almost same as per the present study and nearly one third of students skipped breakfast in the findings. Warren et al (2008) reported that in 47 out morning with significant difference in gender. Another of 80 global health professional students’ survey sites study same reported by Silliman K. et al. that 33% of around the world, over 20% of the medical students subjects consume breakfast never or seldom and Hertsler currently smoked cigarettes; and that in 29 of 77 sites, and Frary studied food behaviour among 212 college over 10% of the medical students currently used other students where 43% reported skipping breakfast more tobacco products.15 Smoking and chewing among males than half the time. Young Japanese subjects revealed documented by the current study but among females a high rate of individuals engaged in skipped eating were not found. Cigarette smoking contributes to a one patterns, the skipping of breakfast has been associated third of all deaths from coronary artery disease; synergy with lower nutritional status with risk of cardiovascular between smoking and other risk factors substantially diseases and It has also been reported that inadequate increases the risks of cardiovascular death associated breakfast habits may contribute to the appearance and with these factors.7 Twelve students consumed more further development of obesity. Therefore, the importance than four cigarettes per day in this study as compared of regular eating patterns cannot be overemphasized in to three students an average 6 cigarettes per day as nutritional education. 9,10,11 in Manna N. et al. study. 14 smoking and chewing of tobacco occasionally found at personal places in present The most prevalent modifiable risk factor was study but greater number of males as compared to none alcohol consumption highly significant among nearly in females. Majority of smokers had initiated smoking one third students in present study and similar results out of curiosity whereas smokeless, smoked tobacco in others study 31.7 % by Kenneth V. Nyombi et al.12 and alcohol consumption increased among medical and Nationwide binge drinking among college students nursing students after admission in college.2,14 exceeding and this higher alcohol consumption rate among students poses questions about the preparedness Physical activity is a major determinant of for curbing NCDs although insignificantly higher alcohol health and decline in physical activity occurs during consumption in single sitting reported in present study adolescence and young adulthood. More than two as compared to other study by Silliman K. et al. that 15% third of the students like recreational activity outside state they usually drink 22 or more drinks per week.13 the campus highly significant as compared to inside Men are heavier drinkers than women in our study campus in contrast to another study shown study along with other study by Silliman K. et al. also confirm population did not have recreational activities in their that male students drink more frequently than female daily life.14 Physical activity exceeding with minimum students.13 Majority of alcohol consumers consumed recommended amount helps improve physical fitness, alcohol either occasionally on party or personal places reduces the risk of chronic diseases, disability and helps in this study and the source of influence during the time prevent unhealthy weight gain. Our study reported that of initiation of alcohol in college was for self-experience two fifth of students had no physical activity and same but majority of them did not make an effort to stop proportion an irregular physical activity respectively consumption of alcohol and same supported by Rustagi beside this regular schedule of physical activity more N. et.al. and Manna N. et al.2,14 than 30 minutes had highly significant among one fifth students. Others study also reported similar pattern of physical activity, inactivity and irregular activities by 150 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Rustagi N. et.al., Srivastava A. et.al., Silliman K. et al., Conflict of Interest - All authors declare that there Manna N.et al.. 2,7,13,14 Males exercise more frequently are no conflicts of interest in this study. with greater intensity level than females and males select Acknowledgement - We sincerely appreciate the strength-training and competitive sports more common support of the medical and nursing students of HIMS. than females was highly significant in our study and 13 same finding reported by Silliman K. et al. study. our References study reported that nearly one fourth students preferred yoga for stress free lifestyle although no physical 1. https://www.who.int/publications/i/item/ncd- activity can be significantly attributed to the lifestyle of progress-monitor-2020. Assessed on 19 august a medical and nursing student that requires long hours 2014. of sitting for curriculum study. Breaks during continued 2. Rustagi N, Taneja DK, Mishra P, Ingle GK. physical inactivity like as standing up, walking down the Cardiovascular Risk Behavior among Students of hall, and others, regardless of physical activity level or a Medical College in Delhi. Indian J Community Med. 2011; 36(1): 51–53. energy expenditure; breaks have been reported to reduce a number of individual NCDs. Therefore, the importance 3. Mano S. Selvan, Anura V krupad. Primary of performing light activities walking or standing in prevention:why focus on children and young between long sedentary hours must be emphasized and adolescents?.Indian journal of Medicine Research 2004;120:511-18 to increase the number of students for engaging in and maintaining regular physical activity habits to increase 4. Garg A. et.al. Prevalence of Risk Factors for general health and to decrease the risk of developing Chronic Non-communicable Diseases Using WHO Steps Approach in an Adult Population in Delhi. NCDs.2,7, JFMPC. 2014; Apr-Jun; 3(2):112-118. Conclusion 5. Mahmood SE. et.al. Lifestyle Disease Risk Factors Among First Year Medical Students in Bareilly. It has been observed that there is much space for NJIRM. 2013; Vol. 4(2); March-April: 50-54. improvement in the diet pattern, addiction habits and 6. Salve SB, Dase RK, Mahajan SM, Adchitre physical activity of medical and nursing students. SA. Nutritional assessment of medical students. Adolescence female students had a greater desire to be International Journal of Medical and Clinical thinner than male students, therefore gender specific Research 2010; 2(1):06-10. interventions may be warranted that different eating 7. Srivastava A. et.al. Epidemiological investigation and exercise pattern exist between male and female of lifestyle associated modifiable risk factors students. Consumption of extra salt, ghee/butter in among medical students. NJMR. 2013; Volume 3; diet, inadequate consumption of fruits and vegetables, Issue 3; July-Sept. habit of skipping breakfast are identified as diet related 8. Mehan MB, Kantharia NB, Surabhi S. Risk Factor modifiable risk factors along with alcohol consumption, Profile of Non-Communicable Diseases in An tobacco chewing, smoking habits and inadequate Industrial Productive (25- 59 Years) Population of physical activity/exercise/yoga for lifestyle diseases but Baroda. J Diab Dev Ctries.2007; 27:116-21. most of them did not put any effort to stop it despite 9. Ruka Sakamaki et. al. Nutritional knowledge, food of receiving the advice. Health education and its habits and health attitude of Chinese university reinforcement especially in the area of high proportion students –a cross sectional study–. Nutrition Journal of fruits and vegetables in diet, alcohol consumption, 2005; 4:4. tobacco chewing, smoking and physical activity is 10. Sakata K, Matumura Y, Yoshimura N, Tamaki J, required. Hashimoto T, Oguri S, Okayama A, Yanagawa Ethical Approval: The study was approved by the : Relationship between skipping breakfast and cardiovascular disease risk factors in the national Institutional Ethics Committee. nutrition survey data. Nippon Koshu Eisei Zasshi Funding- There is nothing sources of funding. 2001; 48:837-41. 11. Ortega RM, Redondo MR, Lopez-Sobaler AM, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 151
Quintas ME, Zamora MJ, Andres P, Encinas- a Healthy Lifestyle in a College Population. Sotillos A. Associations between obesity, breakfast- Californian Journal of Health Promotion 2004; time food habits and intake of energy and nutrients Volume 2; Issue 2:10-19 in a group of elderly Madrid residents. J Am Coll 14. Manna N. et. al. Prevalence of Risk Factors of non- Nutr 1996; 15: 65-72 Communicable Diseases Among Undergraduate 12. Kenneth V. Nyombi et al. High prevalence Medical Students of A Tertiary Care Setting of of hypertension and cardiovascular disease risk West Bengal. IOSR-JDMS. 2016; Volume 15; factors among medical students at Makerere Issue 6 Ver. IV; June; PP 14-19. University College of Health Sciences, Kampala, 15. Warren CW, Jones NR, Chauvin J. Tobacco use Uganda. BMC Res Notes. 2016; 9:110. and cessation counselling: cross-country. Data 13. Silliman K. et al. A Survey of Dietary and Exercise from the Global Health Professions Student Survey Habits and Perceived Barriers to Following (GHPSS), 2005-7. Tobacco Control, 2008; 17:238- 47. 152 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13843 A Study on Prevalence of Cardiovascular Disease Risk Factors Among Medical and Nursing Students, HIMS, Sitapur
Ravi Pachori1, Jiratithigan Sillapasuwan2, Anil Kumar3 1Associate professor, Community Medicine Department, Hind Institute of Medical Sciences (HIMS), Sitapur, U.P. India, 2Lecturer, Department of Mental Health & psychiatric, College of Nursing, Rajabhat university, Pibulsongkram, Thailand, 3Assistant Professor, Pharmacology Department, Baba Raghav Das Medical college (BRDMC), Gorakhpur, U.P. India
Abstract Introduction: CVDs are an emerging public health problem and responsible for about 25 per cent of the DALYs lost due to NCDs in SEAR countries while this trend is rising in younger age group in developing countries where more than three quarters of NCDs deaths occur. Objective: The objective of this study was to assess the prevalence of cardiovascular risk factors among medical and nursing students of HIMS Sitapur, and their association in apparently healthy students. Methodology: A cross-sectional study was carried out in December 2019 among medical and nursing students of HIMS, Sitapur. A total of 820 students which included 496 males and 324 females participated in the study. A Structured questionnaire for anthropometric measurements, blood pressure and fasting blood sugar was recorded among students. Data collection was compiled in MS Excel software and analysed in institutional SPSS version 22. Result: This study has been observed the prevalence of overweight 192 (23.4%) and obesity17 (2%) as per WHO, waist circumference 210 (25.6%) and abnormal waist hip ratio 219 (26.7%), prediabetics 110 (13.4%) in fasting blood sugar and prehypertensive 175 (21.3%) with none of the medical and nursing students either diabetic or hypertensive. Conclusion: Health education and primary level interventions like reducing body weight, blood pressure and blood glucose level have a beneficial impact on these biological CVDs risk factors.
Keywords: CVDs, BMI, prediabetes, prehypertension
Introduction responsible for about 25 per cent of the DALYs lost due to NCDs in SEAR countries while this trend is rising Noncommunicable diseases (NCDs) is a lifestyle in younger age group in developing countries where disease such as cardiovascular diseases (CVDs), cancer, more than three quarters of NCDs deaths occur.1 The diabetes and chronic respiratory diseases, are the leading importance of adolescence also lies in the fact that this global cause of death and are responsible for just over age group has their root causes many serious diseases 70% of deaths worldwide. These NCDs share key risk in adulthood. Growing period, maturation and unique factors like overweight and obesity, raised blood pressure, changes are occurred significantly in adolescence and raised fasting blood sugar, and ultimately diseases which many adult patterns are established during this period, are responsible for 63% of deaths from NCDs and 23% therefore adolescence is the appropriate time period Probability of premature mortality from NCDs in India. for appropriate intervention.2,3 Teenagers start making CVDs are an emerging public health problem and individual choice and develop personal lifestyles which is highly susceptible for adopting unhealthy behaviour Corresponding Author: at individuals’ level in young age and these unhealthy Dr. Ravi Pachori, Associate Professor, Community Medicine behaviours very difficult to modify at later ages or after 4 Department, Hind Institute of Medical Sciences the onset of disease. The objective of this study was (HIMS), Sitapur, U.P. India, Mob.7000050719, to assess the prevalence of cardiovascular risk factors Email:[email protected] among medical and nursing students of HIMS Sitapur, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 153 and their association in apparently healthy students. Hypertension means systolic BP ≥140mmHg and/ or mean diastolic BP ≥ 90mmHg or history of anti- Material and Methods hypertensive treatment fifteen days before the survey This cross-sectional study was carried out in and pre hypertension means as a systolic BP of 130–139 December 2019 among medical and nursing students and/or a diastolic BP of 85–89, according to the JNC- of Hind institute of medical sciences Sitapur, Uttar 7. Two measurements of blood pressure on each study Pradesh, India. A total of 820 students which included participant with a mercury column sphygmomanometer 496 males and 324 females participated in the study. were made using a standardized technique 5 minutes All medical and nursing students who were eligible apart in sitting position. Body mass index (BMI) was and consented to the study were included in the study. calculated by dividing the weight in kilograms by the This study was approved by the Institutional Ethics square of the height in meters. Overweight and obesity Committee and written informed consent was taken were defined as a BMI between 25-30 and BMI ≥30 from each student and absentees, unwilling and those as per WHO criteria and BMI between 23-24.9 and who were sick on the day of data collection were BMI ≥25 as per Asian criteria respectively. Excessive excluded. Purpose of the study was explained to all body fat was defined for waist circumference ≥90 cm medical and nursing students and assured confidentiality in males and ≥80 cm in females and for waist-hip ratio of their responses. A Structured questionnaire was ≥0.9 in males and ≥0.8 in females respectively. Diabetes prepared for anthropometric measurements included mellitus and prediabetic were defined by a fasting blood height and weight, estimation of Body Mass Index sugar of >126 and >110 mg/dl apart and determined by (BMI) as per WHO and Asian criteria, and waist and hip glucometer. Data collection was compiled in MS Excel circumference for calculating Waist-Hip Ratio (WHR). software and analysed in institutional SPSS version Blood pressure and fasting blood sugar was recorded for 22. Variables of CVDs factors were analysed either by all the students. For physical examination, standardized chi square or Fischer exact test, data was presented in calibrated mercury column type sphygmomanometer, percentages (%) and proportions form with statistical stethoscope, common weighing machine, stadiometer significance was considered at 0.05 level. and measuring tape were used and all measurements were taken by the investigators.
Table No: -1. BMI among medical and nursing students as per WHO criteria
Variables Gender Medical Nursing students Total students n (%) Male Female n (%) BMI n (%) n (%) n (%)
Normal 447 (76.8) 164 (67.6) 329 (68.9) 282 (87.0) 611 (74.6) (<25.0)
Overweight 125 (21.5) 67 (29.6) 155 (31.2) 37 (11.4) 192 (23.4) (25.0-29.9)
Obese 10 (1.7) 7 (2.7) 12 (2.4) 5 (1.5) 17 (2.0) (30.0-39.9)
Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100)
Chi square test , d.f.=2 , d.f.=2 p=0.00538 p<0.0001 154 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table No: -2. BMI among medical and nursing students as per Asian criteria
Variables Gender Medical Nursing students Total students n (%) n (%) n (%) Male Female BMI n (%) n (%)
Normal 312 (53.6) 112 (47.1) 234 (47.2) 190 (58.6) 424 (51.7) (<23.0)
Overweight 194 (33.3) 77 (32.3) 174 (35.1) 97 (30.0) 271 (33.0) (23.0-27.5)
Obese 76 (13.1) 49 (20.6) 88 (17.7) 37 (11.4) 125 (15.3) (>27.5)
Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100)
Chi square test .733, d.f.=2 , d.f.=2 p=0.0209 p=0.0029
Table No: -3. Gender wise Waist Circumference (abdominal fat) & Waist Hip Ratio by WHO-Asian criteria among medical and nursing students
Male Female Total Waist circumference n (%) n (%) n (%)
Normal 427 (86.1) 183 (56.5) 610 (74.4)
Waist Circumference 69 (13.9) 141 (43.5) 210 (25.6) (male≥90cm, F≥80cm)
Total 496 (100) 324 (100) 820 (100)
Fisher’s Exact Test , d.f.=1, p<0.0001
Waist Hip Ratio
Normal 409 (82.4) 192 (59.3) 601 (73.3)
Abnormal 87 (17.6) 132 (40.7) 219 (26.7) (male≥0.9, F≥0.8)
Total 496 (100) 324 (100) 820 (100)
Fisher’s Exact Test , d.f.=1, p<0.0001
Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 155
Table No: -4. Prediabetes and diabetes among medical and nursing students as per WHO criteria
Gender Medical Nursing students Total FBS students n (%) Male Female n (%) n (%) n (%) n (%)
Normal 501 (86.1) 209 (87.8) 404 (81.5) 306 (94.4) 710 (86.6) (≤110)
Pre-Diabetes 81 (13.9) 29 (12.2) 92 (18.5) 18 (5.6) 110 (13.4) (110-1265) Total 582 (100) 238 (100) 496 (100) 324 (100) 820 (100)
Fisher’s Exact Test , d.f.=2 , d.f.=2 p=0.5729 p<0.0001
Table No: -5. Prehypertension and hypertension among medical and nursing students
Medical Nursing Blood pressure Total students students (mmhg) n (%) n (%) n (%)
Systolic blood pressure
Normal (<120) 582 (100) 238 (100) 820 (100)
Pre HTN (120-139) 0 0 0
HTN (≥140) 0 0 0
Total 582 (100) 238 (100) 820 (100)
Diastolic blood pressure
Normal (<80) 452 (77.7) 193 (81.1) 645 (78.7)
Pre HTN (80-89) 130 (22.3) 45 (18.9) 175 (21.3)
HTN (≥90) 0 0 0
Total 582 (100) 238 (100) 820 (100)
Fisher’s Exact Test , d.f.=2, p=0.3023 156 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Cont... Table No: -4. Prediabetes and diabetes among medical and nursing students as per WHO criteria
Systolic and diastolic blood pressure
Normal Systolic <120 452 (77.7) 193 (81.1) 645 (78.7) Diastolic <80
Pre HTN Systolic120-139 130 (22.3) 45 (18.9) 175 (21.3) Diastolic 80-89
HTN Systolic ≥140 0 0 0 Diastolic ≥90
Total 582 (100) 238 (100) 820 (100)
Fisher’s Exact Test , d.f.=2, p=0.3023
Result and Discussion different. The reviewed scientific evidence suggest that Table-1 shown BMI range among medical and Asian populations have different associations between nursing students as per WHO criteria of BMI. There was BMI, percentage of body fat, and health risks than do observed prevalence of overweight 192 (23.4%) and European populations. The consultation concluded that obesity17 (2%) and males have highly significant higher the proportion of Asian people with a high risk of type proportion than females. Studies had reported that gain in 2 diabetes and cardiovascular disease is substantial BMI was more likely to be contributed by consumption at BMIs lower than the existing WHO cut-off point 8 of alcohol, eating food low in fibre, consumption for overweight. Table-3 depicts that more than one of caffeine and eating cruciferous vegetables. The fourth of students 210 (25.6%) has been occurred waist obesity causes an approximately threefold increase circumference and nearly same finding with overweight CHD risk.5 The prevalence of overweight was 11.7% while almost three times more in females 141 (43.5%) in a study conducted among medical students of Delhi as compared to males 69 (13.9%), there was a significant and 17.5% among UG medical students by Gupta et increase in number of students with an increased waist al beside this the prevalence of obesity was 3.4% in a circumference highly significant (p<0.001) and other study conducted among medical students of Delhi and study comparison shown that (77.5%) subjects had a 4 2% among UG medical students by Gupta et al that raised waist circumference. Similarly, more than one nearly similar in present study. Our study finding is fourth of students 219 (26.7%) had abnormal waist hip contrast with other studies in which BMI was reported ratio but females 132 (40.7%) had higher proportion as lower among males than females. 6,7 Table-2 shown compared to males 87 (17.6%) highly significant. In BMI range among medical and nursing students as per other study, the prevalence of high waist hip ratio 13 Asian criteria of BMI. There was observed prevalence (7.2%) and 32 (4.63%) respectively that was much lower 9,10 of overweight 271 (33.0%) and obesity 125 (15.3%) as compared to present study. and males have significantly higher proportion than Table-4 shown that 110 (13.4%) of the students had females. Currently, the WHO recommends using both only prediabetics in fasting blood sugar and on the basis international and Asian criteria-based BMI. The cut- of American Diabetes Association definition of diabetes off value for overweight and obese, the values are Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 157
(FBS> 126 mg/dl), none of the students had diabetes. nursing students in this study who are assumed to be This prediabetics changes was more common occurred knowledgeable about CVDs risk factors prevention in nursing students 29 (12.2%) as compared to medical and the challenge is to prevent acquisition of harmful students 81 (13.9%), similarly observed significantly health behaviours among them. Health education and more common in males 92 (18.5%) in comparison to primary level interventions like reducing body weight, females 18 (5.6%). Same finding was seen in other study blood pressure and blood glucose level have a beneficial that Mean fasting blood sugar level was higher among impact on these biological CVDs risk factors. males than females and none of the participants had Ethical approval: The study was approved by the diabetic whereas another study observed that (3.3 %) Institutional Ethics Committee. had pre-diabetic blood sugar level and 3 (1.7 %) were in 5,9 diabetic range. Table-5 depicts that none of the medical Funding- No sources of funding. and nursing students had shown high systolic blood pressure. More than one fifth of students 175 (21.3%) had Conflict of Interest - There are no conflicts of been observed high diastolic blood pressure including interest in this study. medical students had higher proportion 130 (22.3%) as Acknowledgement - We sincerely appreciate the compared to nursing students 45 (18.9%). In contrast to support of the medical and nursing students of HIMS. other study shown that more than one third participants 4 had raised systolic and diastolic blood pressures. References Hypertension is one of the most powerful and prevalent 1. https://www.who.int/publications/i/item/ncd- risk factor for atherosclerotic cardiovascular disease, progress-monitor-2020. Assessed on 19 august although our study found interesting results of blood 2020. pressure measurement in medical and nursing students that majority of the students 645 (78.7%) had normal 2. Rustagi N, Taneja DK, Mishra P, Ingle GK. Cardiovascular Risk Behavior among Students of blood pressure and this finding is close to documented by a Medical College in Delhi. Indian J Community Mehan et. al. and in contrast prevalence of hypertension Med. 2011; 36(1): 51–53. was observed to be 7.16% in the Delhi study by 3. Mano S. Selvan, Anura V krupad. Primary Chhabra et, al..5,6,12 Raise a concern on hypertension and prevention: why focus on children and young associated CVD risk factors are creeping into the young adolescents?.Indian journal of Medicine Research age bracket and over time putting the future generation 2004;120:511-18 at an increased risk of CVDs that may increase morbidity 4. Garg A. et.al. Prevalence of Risk Factors for and decrease productivity. Increased weight is associated Chronic Non-communicable Diseases Using WHO with cardiovascular system changes like fat deposition Steps Approach in an Adult Population in Delhi. in the vessel lumen which eventually lead to elevated JFMPC. 2014; Apr-Jun; 3(2):112-118. blood pressures.9 5. Srivastava A. et.al. Epidemiological investigation Conclusion of lifestyle associated modifiable risk factors among medical students. NJMR. 2013; Volume 3; It has been observed in current study that risk factors Issue 3; July-Sept. of CVDs are commonly prevalent like as overweight, 6. Chhabra P, Grover VL, Aggarwal K, Kannan AT. obesity, high waist circumference and waist hip ratio, Nutritional status and blood pressure of medical prediabetic and prehypertensive changes among medical students in Delhi. IJCM. 2006; 31(4):248-250. and nursing students at their young age and may progress 7. Gupta S, Ray TG, Saha I. Overweight, obesity further with time which is alarming and definitely and influence of stress on body weight among require early identification and intervention in the form undergraduate medical students. Indian J of primary level prevention. The National Program for Community Med. 2009; 34(3): 255–257. Prevention and Control of Diabetes, Cardiovascular 8. WHO Expert Consultation Appropriate body mass disease and Stroke has been launched focusing on index for Asia populations and its implications disease prevention and health promotion. Medical and for policy and intervention strategies. Lancet. 158 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
2004;363:157–63. GJMEDPH. 2012. Vol.1(3); May-June; 24-26. 9. Kenneth V. Nyombi et al. High prevalence of 11. Mahmood SE. et.al. Lifestyle Disease Risk Factors hypertension and cardiovascular disease risk factors Among First Year Medical Students in Bareilly. among medical students at Makerere University NJIRM. 2013; Vol. 4(2); March-April: 50-54. College of Health Sciences, Kampala, Uganda. 12. Mehan MB, Kantharia NB, Surabhi S. Risk Factor BMC Res Notes. 2016; 9:110. Profile of Non-Communicable Diseases in An 10. MM Akheel. et. al. Prevalence of risk factors of Industrial Productive (25- 59 Years) Population of ischemic heart disease among students of J N Baroda. J Diab Dev Ctries.2007; 27:116-21. Medical College in Belgaum, Karnataka, India. DOI Number: 10.37506/ijphrd.v12i1.13844 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 159 Prevalence of MRSA and its Antibiotic Susceptibility Pattern in a Tertiary Care Center,Karimnagar
G. Sowjanya1, Archana ARK1, G Swetha1, V.Praveen Kumar2 1Assistant Professor, Chalmeda Anand Rao institute of Medical Sciences, Karimnagar, Telangana, India, 2Associate Professor Department of Microbiology, Chalmeda Anand Rao Institute of Medical sciences, Karimnagar, Telangana, India
Abstract Background & Objectives: Methicillin-resistant Staphylococcus aureus (MRSA) is a well-recognized public health problem throughout the world.This study was aimed to isolate the Staphylococcus aureus from various clinical specimens, and to study the prevalence of methicillin resistance among Staphylococcus aureus and to evaluate phenotypic and genotypic methods in detection of MRSA and to determine its Aantibiotic susceptibility pattern in MSSA and MRSA isolates. The study was undertaken during November 2018to October 2019.various clinical samples received from the surgical and medical departments are included in the study.
Methods:Total 218 staphylococcus aureus strains were isolated from various clinical samples S. aureus was identified by characteristic growth on blood agar, MacConkey agar, Gram staining and various biochemical tests, e.g. catalase test, free and bound coagulase test, and anaerobic mannitol fermentation1. Among them 48(22.01%) were MRSA positive 170(77.9%) were MSSA
Conclusion: Early identification of MRSA is an important step toward timely implementation of appropriate treatment. The prevalence of resistance is bound to increase with increased irrational use of antibiotics. Robust antimicrobial stewardship and strengthened infection control measures are required to prevent spread and reduce emergence of resistance.
Keywords:MRSA, MSSA, Vancomycin, Teicoplanin, Antimicrobial Susceptibility.
Introduction MRSA is now a common cause of serious hospital- acquired infections. MRSA can be clinically grouped Methicillin-resistant Staphylococcus aureus as community-associated (CA-MRSA) or hospital/ (MRSA) strains or multidrug-resistant S. aureus, healthcare-associated (HA-MRSA).2At present, initially described in 1960s, emerged in the last decade healthcare-associated methicillin-resistant S.aureus as a cause of nosocomial infections responsible for (HA-MRSA) is associated with significant mortality rapidly progressive, potential fatal diseases including and morbidity (longer hospital stays) and imposes a life-threatening pneumonia, necrotizingfasciitis, serious economic burden on scarce healthcare resources endocarditis, osteomyelitis, severe sepsis, andtoxinoses worldwide1. such as toxic shock syndrome1. In India, high rates of MRSA have been reported Corresponding Author: in clinical isolates from various studies, with rates as Dr. V.Praveen Kumar high as 54.8% (ranging between 32% and 80% among Associate Professor, ChalmedaAnand Rao institute of the S. aureus pool)3. Methicillin resistance is due to the Medical sciences, Karimnagar, Telangana, production ofpenicillin binding protein (PBP) PBP2a Mobile: +91 8142037662 which has less affinity to beta lactam drugs and itis Email:[email protected] mediated by mecAgenes. In India reported MRSA 160 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 incidence varies from29.10% to 54.9%.5 supplied by takara emerald master mix kit(7). Antimicrobial susceptibility testing.:The Kirby Bauer Materials and Methods disc diffusion method was used routinely to detect the The study was conducted during the period of sensitivity of all S. aureus isolates and interpretations november 2018 to october 2019. a total of 218 strains were made according to CLSI guidelines. All discs of S. aureus, isolated consecutively from various clinical were supplied by Hi-Media. For MRSA, Cotrimoxazole samples in the Department of Microbiology, Chalmeda (25 µg), Erythromycin (15 µg), Clindamycin (10 Anand Rao Institute of Medical Sciences & Hospital, µg),Chloramphenicol (30μg),Gentamicin (10 μgm), Karimnagar, Telangana,India, was evaluated. The Ciprofloxacin (30 µg),Amikacin (10 µg), Linezolid (30 clinical samples from which the strains were isolated µg), Vancomycin (30 µg) and were tested. For MSSA, were wound swab, urine,catheter tip,blood,sputumand the same antibiotics as for MRSA were used, as well as stool. S. aureus was identified by characteristic growth on ampicillin (10 µg), and Amoxicillin/Clavulanic acid (30 Blood agar, MacConkey agar, Gram staining and various µg). biochemical tests, e.g. catalase test, free and bound Results coagulase test, and anaerobic mannitol fermentation4 Among 7224 samples processed during the study, Screening of MRSA was done using cefoxitin disc 218 showed culture positivity for S.aureus. Out of 218 (30μg) as per CLSI recommended disc diffusion method. S. aureus, 48 isolates were MRSA by cefoxitin disc 0.5 McFarland standard inoculum of Staphylococcus diffusion method, confirmed by oxacillin broth dilution aureus were inoculated on Muller hinton agar and MIC method and mecA gene was detected by PCR in Cefoxitin disc was placed on it and plates were all the isolates (Table1)31(64.5%) of MRSA isolates o incubated at 35 c for 18 hrs. Zone diameter of ≤21 mm were from male patients and 17(35.41%) from female was considered as methicillin resistance and ≥22 mm patients, Highest number of staphylococcus aureus were 5 was reported as sensitive. recovered from pus samples136(62.38%) followed by Determination of Minimum Inhibitory urine 35(16.05%) ,catheter tip21(9.6%),blood11(5.04%), Concentrations (MICs) of OxacillinMICs of oxacillin sputum7(3.2%), BAL 5(2.2%), stool 3(1.3%)Most of the (Table 1) for all isolates of Staphylococcus aureus were MRSA isolateswere resistant to commonly prescribed determined by broth microdilution method as described antibiotics,All the isolates of MRSA(48) andMSSA by Andrews and CLSI M07-A9 guidelines. The results (170) exhibited 100% sensitivity to Tigecycline.MRSA were interpreted according to CLSI guidelines. The isolates exhibited highest resistance compared to serial dilutions of oxacillin concentrations were made MSSA isolates.MRSA isolates exhibit 100% resistance from 0.0125 μg/mL to 128 μg/mL6 to Ampicillin followed by Ciprofloxacin(79.16%), Erythromycin(77.8%), Chloramphenicol(75%), Detection of mecAgene: Extraction of DNA Gentamicin (58.3%). Of the 35 isolates from urine tested was performed by CTAB (Cetyltrimethylammonium for Nitrofurantoin and Nalidixic acid MSSA and MRSA bromide) method mecA gene was detected by usingThe exhibited 20(57.14%) and (42.85%) respectively. primer mecAF (5′-actgctactcaccctcaaac-3′) and the reverse primer mecAR (5′-ctggtgaagttgtaatctgg-3′)
Table 1: Comparison of the phenotypic and genotypic methods for detection of MRSA.
Cefoxitin disc diffusion oxacillin broth microdilution Polymerase chain reaction
Strains of S. aureus having zone of Strains of S. aureus having oxacillin Strains of S.aureus inhibition of ≤21 mm to cefoxitin MIC of ≥4 μg/mL disc (30 μg) harboringmecA gene (48) (48) (48) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 161
Table 2: Specimen wise distribution of staphylococcus aureus
Specimen Sample number Percentage
Wound swab 136 62.38%
Urine 35 16.05%
Catheter tip 21 9.6%
Blood 11 5.04%
Sputum 7 3.2%
BAL 5 2.2%
Stool 3 1.3%
Table 3:Antibiotic susceptibility results of Staphylococcus aureus Nov 2018- Oct 2019
MSSA(170) MRSA(48) Antibiotic No of smplesResistant(% No of samples Resistant(%)
Erythromycin 45 26.47 37 77.08
Clindamycin 24 14.11 22 45.83
Chloramphenicol 126 74.11 36 75
Gentamicin 30 17.64 28 58.33
Co-trimaxazole 46 27.05 26 54.16
Ciprofloxacin 79 46.47 38 79.16
Vancomycin 0 3 6.25
Linezolid 0 0 2 4.16
Amoxyclav 74 43.52 34 70.83
Teicoplanin 0 0 1 2.08
Tigecycline 0 0 0 0
100 ampicillin 163 95.83 48 162 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Discussion one of the drug of choice for MRSA infection these are effective antibiotics and thus should not be misused and This study was designed to determine the occurrence should preserved for future decades in preventing the of MRSA in S. aureus isolates from various clinical development of drug resistance. Hence it is necessary samples The overall MRSA prevalence in our study was to establish an antimicrobial susceptibility surveillance 48 samples (22.01%) our study correlated with other system and to improve current infection control programs studies according to sader HS et al the prevalence of in health care institutes to prevent the spread of resistant MRSA was 22.5%7. According to Mehta et al, verma microorganisms. et al ,velasco et al the prevalence of MRSA may varies (8,9,10,) between 20 and 40%. . In India, high rates of Conflicts of Interest: NIL MRSA have been reported in clinical isolates from various studies, with rates as high as 54.8% (ranging Source of funding: Self between 32% and 80% among the S. aureus pool)4. Ethical Clearance: Clearance taken from In this study staphylococcus aureus was ‘ChalmedaAnand Rao Institute of Medical sciences predominantly isolated from pus sample(62.38%) which ethical Committee’. is inaccordance with other studies(11,12,13,)followed by References urine(16.05%),catheter tip( 9.6%), Blood (5.04%), sputum (3.2%), BAL(2.2% ), and stool (1.3%)Similar 1. Eyob YohanessGaroy et al,Methicillin-Resistant higher rate of isolation of S.aureus from pus were Staphylococcus aureus (MRSA): Prevalenceand reported by Rashmi et al. &Jeydev Pandya et al.(14,15) The Antimicrobial Sensitivity Pattern among predominance in pus could be due to exposure of wound PatientsAMulticenter Study in Asmara,volume to microorganism in the environment and S.aureus 2019,article ID 8321834,9 pages present on skin as commensal makes the wound more 2. Abdul H. Siddiqui et al Methicillin Resistant prone for infection. MRSA is considered in opportunistic Staphylococcus Aureus (MRSA); JanakKoirala. human pathogen with demonstrated capacity to aquire Author Information Authors Abdul H. Siddiqui1; more resistance to nearly overall antibiotics used to Janak Koirala2.In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.2020 treat it.Vancomycin is the drug of choice for treatment Jul 19. of MRSA cases in our study we reported 2(4.1%) vancomycin resistance similar findings(3.92%) are 3. R. Laxminarayan and R. R. Chaudhury, “Antibiotic resistance in india: drivers and opportunities for reported by jyothi kumari et al from manipal16 action,” PLoS Medicine, 2016,13,( 3,) p. e1001974 In our study we reported 1(2.08%)in contrast to 4. Baird D et al. Staphylococcus: cluster forming Harcharan Singh et al fom rajasthan reported 12% of Gram positive cocci. . In Mackie and McCartney: linezolid resistance17 In contrast to Shariq et al from Practical Medical Microbiology, , 14th edn., pp. pakistan, Priya Datta et al from chandighar reported 245––258. 100% sensitivity to linezolid(18,19)All MRSA isolates 5. Dr S. Senthamarai et al Prevalence of methicillin showed high level of resistance to commonly prescribed resistant of Staphylococcus aureus (MRSA) its antibiotics than MSSA in we observed 100% to ampicillin antibiotic susceptibility pattern from various and ciprofloxacin(79.1%) Similar findigs were observed clinical specimens in a tertiary care hospital. by avinash et al who observed 100% resistance to SJMSCR 2019,7(2), 129-132 ampicillin and 81.3% restant to amoxyclav20 6. Raghabendraadhikari et al Detection of Methicillin Resistant Staphylococcus aureus and Determination Conclusion of Minimum Inhibitory Concentration of Vancomycin for Staphylococcus aureus Isolated This study reveals Cefoxitin disc diffusion method from Pus/Wound Swab Samples of the Patients gives promising results compared with Oxacillin agar Attending a Tertiary Care Hospital in Kathmandu, dilution method and mecA gene detection by PCR. Can J Infect Dis Med Microbiol. 2017; 2017: Tigecycline, Teicoplanin and Linezolid found to be 2191532.Published online 2017 Jan 5. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 163
7. Sader HS, Farrell DJ, Jones RN. Antimicrobial 14. M.S. Rashmi1, S. Krishna and SumairaQayoom, susceptibility of Gram-positive cocci isolated from Prevalence of MRSA amongClinical Isolates skin and skin-structure infections in European of Staphylococcus aureus and its Antibiotic medical centres. Int J Antimicrob Agents. Susceptibility Pattern at a Tertiary Care Hospital, 2010;36:28–32. Int.J. Curr. Microbiol.App.Sci (2017) 6(1): 747- 8. Mehta A. P. , Rodrigues C. , Sheth K. , Jani S. 749 747. , Hakimiyan A. , Fazalbhoy N. . . Control of 15. Jaydev Pandya and MiteshKamothi Antibiotic methicillin resistant Staphylococcus aureus in a Sensitivity Pattern and Prevalence of Methicillin tertiary care centre: a five year study. . Indian J Med Resistant Staphylococcus aureus (MRSA) at Microbiol 1998,16:, 31––34. Tertiary Care Hospital, Int. J. Curr. Microbiol.App. 9. Velasco D. , del Mar Tomas M. , Cartelle M. , Beceiro Sci (2017) 6(11): 423-430 42. A. , Perez A. , Molina F. , Moure R. , Villanueva 16. jyothikumar et al comparision of E test and R. , Bou G. Evaluation of different methods for agar diliution for determining minimum inhibitory detecting methicillin (oxacillin) resistance in concentration of vancomycin to health care Staphylococcus aureus . . J AntimicrobChemother associated methicillin resistant staphylococcus 2005,55:, 379––382. aureus Asian journal of pharmaceutical and clinical 10. Verma S. , Joshi S. , Chitnis V. , Hemwani N. , research.2016,9(4),189-191 Chitnis D. . . Growing problem of methicillin 17. Harcharan Singh et al. Antibiotic Susceptibility resistant staphylococci – Indian scenario. . Indian J Pattern Of Methicillin Resistance Staphylococcus Med Sci2000,54:, 535––540. Aureus In Tertiary Care Center At Southern 11. Trivedi MB, Mahendra V, Sumeeta S: Prevalence Rajasthan.international journal of pharmaceutical of methicillinresistant Staphylococcus aureus in science and research 2014,5(2) 607-611 various clinical samples in a tertiary-care hospital 18. Shariq, et al Evaluation of various methods for the samples in a tertiary-care hospital. Int J Med Sci detection of Susceptibility profile of methicillin- Public Health 2015; 4:1735-1738. resistant Staphylococcus aureus to linezolid in 12. Indian Network for Surveillance of Antimicrobial clinical isolates Ali 2017 Jan-Mar; 11(1): 1–4. Resistance (INSAR) group, India, Methicillin 19. PriyaDatta et al ,meticillin-resistant Staphylococcus resistant Staphylococcus aureus(MRSA) in India: aureus strainsand susceptibility patternsIndia Prevalence & susceptibility pattern, Indian J Med Journal of Medical Microbiology (2011), 60, 1613– Res 137, 2013, 363-369. 1616 13. Shah VP, Mundra N, Vachhani N, Shah HY, 20. Avinash Kumarand Anshul Kumar Prevalence Gadhvi H, ShingalaH,et al. All prevalence and of Methicillin Resistant Staphylococcus Aureus antibiotic susceptibility pattern of methicillin- (MRSA) In A SecondaryCare Hospital In North resistant Staphylococcus aureus in a tertiary care Eastern Part of IndiaResearch Article 2018,2(1),1- hospital, Jamnagar, Gujarat. Int J Sci Res 2012; 2. 1(3):2277–9. 164 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13845 Relationship between Coping Styles and Conversion Disorder Phenomenology: A Study from Eastern India
Soumen Nandi1 , Rajarshi Chakravarty1, Somsubhra Chattopadhyay1, Shuvendu Datta1, Kanika Das1, Supantha Chatterjee1 1NRS Medical College, Kolkata, Burdwan Medical College and Hospital, Burdwan,West Bengal
Abstract Background: Conversion disorder is a Functional Neurological Disorder under DSM-5 classification which arises mainly due to psychological conflicts and without any underlying clinical findings and/or biochemical abnormalities .Studies in the past have attributed faulty coping styles for genesis and maintenance of conversion disorder.Here we attempted to identify any socio-demographic variable and coping style that may be associated with the patients of Conversion disorder.
Aim:To study the socio-demographic variables ,clinical presentation ,coping styles adopted in patients of Conversion disorder.
Methods: 51 patients of conversion disorder fulfilling the inclusion criteria of the study were evaluated for socio-demographic variables, clinical features, coping styles using semi-structured pro forma.
Conclusion : Our population consisted of young adults(mean-30 yrs),mostly females(82%).Most of our patients were married(69%), comprising of housewives or students.43 % of the population had a past history of similar illness and a similar proportion had significant stressor provoking current episodes.
Predominant symptoms were unresponsiveness(39%) followed by SOB/palpitation(25%).The most used coping strategy was religious coping(94%) followed by “venting of emotions”(75%).Education, and Hinduism played minor protective roles while presence of stressor deployed both good and bad coping strategies and thus identified as the most vulnerable group in need of treatment .
Key words: Conversion, problem-focussed coping, emotion focused coping, stressor.
Introduction precipitated or aggravated by a psychological stressful event(conflict)[1][2]The symptoms are produced ,though Conversion disorder is a disorder characterised by not consciously ,to get relief from the psychological motor, sensory, autonomic symptoms. The symptoms conflict(Primary gain) and also to get attention can affect multiple areas of the body(though not from significant others(Secondary gain).Conversion simultaneously) and cannot be explained by laboratory patients form a major portion of psychiatric patients tests or physical conditions. There is an underlying in developing countries[3][4][5]. Previous Indian studies theme of loss of integrity between consciousness, evaluating clinical phenomenology have highlighted memory and and identity .i.e dissociation. There may the role of stress[6][7] and ‘modeling’[8] in producing be associated loss of sensation and loss of control of conversion symptoms. However in DSM-5 ,a separate body movements which are supposed to have been category called ‘functional neurological disorder’ has come for episodes removing the need for obvious [9] [10] Corresponding author: stressors . Previous Indian studies also stressed Dr. Rajarshi Chakravarty that female sex, young age, low socio-economic status, Burdwan Medical College and Hospital,Burdwan,West joint family and illiteracy are potent risk factors for Bengal-713104, email: [email protected] developing conversion. Illiterates and housewives were Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 165
noted to be at highest risk.[11]However a recent study[12] of conversion disorder according to DSM-IV TR criteria. found some contrasting characteristics regarding Consecutive diagnosed patients of conversion (using literacy and occupation of subjects(e.g students being DSM-IV TR) were then interviewed for studying the the predominant sufferers).This finding and a dearth socio-demographic characteristics ,clinical features and of studies regarding socio-demographic data and coping strategies for a 6-month period from July 2012 to symptomatology in conversion patients of West Bengal December 2012. prompted us to take up this study. Inclusion Criteria: Coping is any effort at stress or conflict management. Cases obeying the criteria for conversion disorder [13][14] These are done when demands are too taxing for according to DSM-IV TR were included . the individual. It is mainly the strategies adopted by an individual in a stressful situation. Age >14 yrs
Coping may be of major two-types: problem focused Exclusion Criteria: coping and emotion-focussed coping.[15] No organic underlying cause.People with mental Problem -focused coping strategies are directed retardation were excluded from study. towards reducing or eliminating a stressor.[15] The COPE Inventory[16] Identifies active coping, planning, TOOLS: suppression of competing activities, restraint coping, 1) Structured clinical Interview for diagnosis seeking of instrumental social support as various types according to DSM-IV(SCID) of problem-focussed coping . 2) Semi-structured pro forma incorporating the Emotion-focussed coping strategies are directed age, sex, marital status, education, occupation past and towards changing ones emotional reaction.[15] The family history, clinical features was used. COPE inventory[16] include seeking of emotional social support, positive reinterpretation, acceptance, denial, 3) COPE Inventory :Multidimensional inventory to religious coping as various types of emotion-focussed assess the different ways in which different people react coping. to stress.
Ineffective strategies include: venting of emotions, 5 scales measure aspects of problem focused behavioural disengagement, mental disengagement. coping(active coping, planning, suppression of These are mainly emotion-focussed but maladaptive.[16] competing activities, restraint coping, seeking of instrumental social support); 5 scales measure aspects Meta-analyses of studies outside India have stressed of emotion-focused coping (seeking of emotional social the use of religious strategies for coping.[17] support, positive reinterpretation, acceptance, denial, DSM-5 have recently removed the need of turning to religion); and 3 scales measuring less useful underlying stressors for establishing diagnosis of coping responses (focus on and venting of emotions, Conversion disorder. behavioral disengagement, mental disengagement). Cronbach’s alpha for most items ranged above 0.6, Material and Methods which is quite acceptable.[15] Design: Results and Discussion It is a cross sectional descriptive study including Results: diagnosed patients of conversion disorder. The socio-demographic variables of our study Methodology population are recorded in table 1.
The psychiatric referrals from chest and medicine The mean age of our study population was 30.25 yrs. indoor patients department were screened for diagnosis The females greatly outnumbered males(82.4% vs 17.6%). 166 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Most of the people were Hindus(52.1%),married(68.6%). shortness of breath, chest pain) (25.5%) and pseudo- Most of the population consisted of housewives(54.9%) seizures(17.6%). followed by students(17.6%).43.1% had a past history On evaluation we found that 45.1% had an obvious of similar illness.Details of demographic variables have stressor prior to the incident while 54.9% had no been depicted in Table 1. significant stressor. Nearly all stressor were related to Most common presenting symptom(39.2%) problem with spouses/primary support group. Nearly were unresponsiveness; followed by respiratory(like 43% had previous history of similar episodes of conversion.
TABLE 1 Socio-demographic profile of our conversion patients Mean age 30.5 yrs(range14-40 yrs)
Sex Female: male4.7:1
Religion Hindus-52.1%;Muslims-47.9%
Married-68.6%,Unmarried-21.6%,widowed-5.9%,Divorced- Marital status 2%,Remarried-2%
Past History Present-43.1%;absent-56.9%
Graduates 29.4%
Illiterates 23.5%
Primary school completed 13.7% Educational status Middle school completed 15.7%
High school completed 9.8%
Higher secondary 7.8%
Housewives 54.9%
Students 17.6%
Semiskilled worker/ 11.8% Laborer Occupation Business 5.9%
Teacher 5.9%
Unemployed 3.9%
Now we applied the COPE inventory to assess the coping strategies used.
Regarding problem focused coping strategies ‘restraint’ was significantly unused(86%).’Active coping’ and ‘planning’ was used by 53% and 51% respectively while ‘suppression’ and ‘instrumental social support’ were used by 47% and 41% respectively Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 167
Regarding emotion-focused coping strategies, the Suppression usage did not show marked strategies named ‘acceptance’ and ‘emotional support’ variability(57% vs 48%);here also it was used were used by 43% and 49% respectively; ‘religious’ sparingly(29%) strategy was used by almost all(94%);whilst denial Instrumental support use increased with age(14% to and positive reinterpretation were rejected almost 56%). uniformly(96% and 98% respectively). The use of acceptance however decreased with As regards the less useful strategies, ’behavioral age(86% vs 32%) while use of emotional support disengagement’ was used by 57% ;’venting of emotions’ strategy somewhat increased with age(42% vs 64%). was used frequently(75%) and ‘mental disintegration’ was used relatively infrequently(33%). The usage of ‘behavioural disengagement’ as a strategy showed marked decline with age(100% vs Thus it appears that the significant coping strategies 44%) while that of venting increased somewhat(57% vs include: active coping, planning ,acceptance, suppression, 72%);highest use was seen by the middle strata(90%). instrumental social support, emotional support, behavioral disengagement, mental disengagement and Mental disintegration use was lowest In oldest venting of emotions. strata(20%);in other age-strata it was used more or less uniformly(40-50%). The patients were stratified into 5 age groups(14-19 yrs,20-24 yrs,25-29 yrs,30-34 yrs,35-40 yrs) and then Now we tried to find out the coping strategies studied the various coping strategies with age. according to sex, religion, marital status, occupation etc. The table below shows usage of various coping strategies Active coping was used differently by the youngest in our subjects according to sex , religion , past history and oldest strata(29% vs 64%); whilst planning was not and presence of stressful events. (43% vs 56%).Use of ‘planning strategies’ was lowest in middle strata(29%).
TABLE 2: COPING STRATEGIES USED VS CLINICO-DEMOGRAPHIC CHARACTERISTICS-I
PAST RELIGION(Figure STRESSOR(Figure SEX(Figure in bracket HISTORY(Figure in bracket denote in bracket denote denote percentages) in bracket denote percentages) percentages) COPING STRATEGY percentages) Male Female Hindu Muslims Present Absent Present Absent (n=9) (n=42) (n=27) (n=24) (n=22) (n=29) (n=23) (n=28) Present 6(66) 21(50) 18(66) 9(38) 12(55) 15(52) 16(70) 11(39) Active coping Absent 3(33) 21(50) 9(33) 15(62) 10(45) 14(48) 7(30) 17(61) Present 7(78) 19(45) 16(59) 10(42) 12(55) 15(52) 15(65) 11(39) Planning Absent 2(22) 23(55) 11(41) 14(58) 10(45) 14(48) 8(35) 17(61) Present 3(33) 19(45) 12(44) 10(42) 11(50) 11(38) 13(57) 9(32) Acceptance Absent 6(66) 23(55) 15(56) 14(58) 11(50) 18(62) 10(43) 19(68) Present 6(66) 18(43) 13(48) 11(46) 13(59) 11(38) 13(57) 11(39) Suppression of competing activities Absent 3(33) 24(57) 14(52) 13(54) 9(41) 18(62) 10(43) 17(61) Present 2(22) 19(45) 13(48) 8(33) 10(45) 11(38) 12(52) 9(32) Instrumental Support Absent 7(78) 23(55) 14(52) 16(67) 12(55) 18(62) 11(48) 19(68) Present 3(33) 22(52) 15(56) 10(42) 12(55) 13(45) 16(70) 9(32) Emotional support Absent 6(66) 20(48) 12(44) 14(58) 10(45) 16(55) 7(30) 19(68)
Behavioural Present 4(44) 25(60) 14(52) 15(63) 15(68) 14(48) 10(43) 19(68) disengagement Absent 5(56) 17(40) 13(48) 9(37) 7(32) 15(52) 13(57) 9(32) Present 2(22) 15(36) 6(22) 11(46) 6(27) 11(38) 7(30) 10(36) Mental disengagement Absent 7(78) 27(64) 21(78) 13(54) 16(73) 18(62) 16(70) 18(64)
Venting out of Present 5(56) 33(79) 20(74) 18(67) 17(23) 21(72) 21(91) 17(61) emotions Absent 4(44) 9(21) 7(26) 6(33) 5(77) 8(28) 2(9) 11(39) Present 4(44) 0(0) 3(11) 1(4) 1(5) 3(10) 3(13) 1(4) Substance use Absent 5(55) 42(100) 24(89) 23(96) 21(95) 26(90) 20(87) 27(96) 168 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3 shows coping strategies used vs rest of clinico-demographic characters(Marital status and system involved)
MARITAL STATUS(Figures in bracket indicate SYMPTOMS(Figures in bracket denote percentages) percentages) COPING STRATEGY Married Unmarried widow Divorced remarried Chest Convulsion LOC Paralysis Multiple (n=35) (n=11) (n=3) (n=1) (n=1) (n=13) (n=9) (n=20) (n=3) (n=6)
Present 19(54) 6(55) 2(66) 0(0) 0(0) 7(54) 5(56) 9(45) 2(67) 4(67) Active coping Absent 16(46) 5(45) 1(33) 1(100) 1(100) 6(46) 4(44) 11(55) 1(33) 2(33)
Present 17(49) 8(73) 1(33) 0(0) 0(0) 7(54) 6(67) 7(35) 2(67) 4(67) Planning Absent 18(51) 3(27) 2(67) 1(100) 1(100) 6(46) 3(33) 13(65) 1(33) 2(33)
Present 14(40) 7(64) 0(0) 1(100) 0(0) 8(62) 4(44) 8(40) 0(0) 2(33) Acceptance Absent 21(60) 4(36) 3(100) 0(0) 1(100) 5(38) 5(56) 12(60) 3(100) 4(67)
Suppression Present 15(43) 7(64) 1(33) 1(100) 0(0) 8(62) 5(56) 6(30) 2(67) 3(50) of competing activities Absent 20(57 4(36) 2(67) 0(0) 1(100) 5(38) 4(44) 14(70) 1(33) 3(50)
Present 16(46) 2(18) 2(67) 1(100) 0(0) 3(23) 3(33) 9(45) 2(67) 4(67) Instrumental Support Absent 19(54) 9(82) 1(33) 0(0) 1(100) 10(77) 6(67) 11(55) 1(33) 2(33)
Present 18(51) 4(36) 2(67) 1(100) 0(0) 5(38) 3(33) 10(50) 2(67) 5(83) Emotional support Absent 17(49) 7(64) 1(33) 0(0) 1(100) 8(62) 6(67) 10(50) 1(33) 1(17)
Present 18(51) 8(73) 1(33) 1(100) 1(100) 6(46) 4(44) 13(65) 2(67) 4(67) Behavioural disengagement Absent 17(49) 3(27) 2(67) 0(0) 0(0) 7(54) 5(56) 7(35) 1(33) 2(33)
Present 10(29) 5(45) 1(33) 0(0) 1(100) 4(31) 4(44) 7(35) 1(33) 1(17) Mental disengagement Absent 25(71) 6(55) 2(67) 1(100) 0(0) 9(69) 5(56) 13(65) 2(67) 5(83)
Present 26(74) 8(73) 3(100) 0(0) 1(100) 10(77) 5(56) 15(75) 2(67) 6(100)
Venting out of emotions Absent 9(26) 3(27) 0(0) 1(100) 0(0) 3(23) 4(44) 5(25) 1(33) 0(0)
Present 3(9) 1(9) 0(0) 0(0) 0(0) 2(15) 1(11) 0(0) 1(33) 0(0) Substance use Absent 32(91) 10(91) 3(100) 1(100) 1(100) 11(85) 8(89) 20(100) 2(67) 6(100)
TABLE 3:USAGE OF COPING STRATEGIES VS CLINIC-DEMOGRAPHIC CHARACTERISTICS-II Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 169
Table 4 assesses the usage of various coping strategies vs rest of clinic-demographic variables(Occupation and education
EDUCATION(Fig in bracket show percentages) OCCUPATION(Fig in bracket show percentages)
Illiterate Post- High COPING STRATEGY Primary Middle H.S Housewife Student Teacher Unemployed school Semiskilled Business( (n=12) grad worker(n=6) n=3) (n=7) (n=8) (n=4) (n=28) (n=9) (n=3) (n=2) (n=5) (n=15)
Present 5(42) 1(14) 5(63) 2(40) 3(75) 11(73) 12(42) 6(67) 3(50) 3(100) 2(66) 1(50) Active coping Absent 7(58) 6(86) 3(37) 3(60) 1(25) 4(27) 16(58) 3(33) 3(50) 0(0) 1(33) 1(50)
Present 5(42) 0(0) 4(50) 2(40) 4(100) 11(73) 9(32) 7(78) 4(67) 3(100) 2(66) 1(50) Planning Absent 7(58) 7(100) 4(50) 3(60) 0(0) 4(27) 19(68) 2(22) 2(33) 0(0) 1(33) 1(50)
Present 3(25) 4(57) 5(63) 2(40) 2(50) 6(40) 10(36) 5(56) 3(50) 1(33) 2(66) 1(50) Acceptance Absent 9(75) 3(43) 3(37) 3(60) 2(50) 9(60) 18(64) 4(44) 3(50) 2(67) 1(33) 1(50)
Present 5(42) 1(14) 5(63) 2(40) 1(25) 10(67) 9(32) 6(67) 4(67) 2(67) 2(66) 1(50) Suppression Absent 7(58) 6(86) 3(37) 3(60) 3(75) 5(33) 19(68) 3(33) 2(33) 1(33) 1(33) 1(50)
Present 6(50) 3(43) 2(25) 1(20) 1(25) 8(53) 13(46) 3(33) 3(50) 0(0) 2(66) 0(0) Instrumental 2 Support Absent 6(50) 4(57) 6(75) 4(80) 3(75) 7(47) 15(54) 6(67) 3(50) 3(100) 1(33) (100)
Emotional Present 6(50) 4(57) 3(37) 1(20) 1(25) 10(67) 14(50) 4(44) 4(67) 0(0) 2(66) 1(50)
support Absent 6(50) 3(43) 5(63) 4(80) 3(75) 5(33) 14(50) 5(56) 2(33) 3(100) 1(33) 1(50)
Behavioural Present 6(50) 7(100) 5(63) 3(60) 1(25) 7(47) 17(61) 6(67) 4(67) 0(0) 1(33) 1(50) diseng- Absent 6(50) 0(0) 3(37) 2(40) 3(75) 8(53) 11(39) 3(33) 2(33) 3(100) 2(66) 1(50) agement 3 Mental diseng- Present 4(33) 2(29) 5(63) 2(40) 1(25) 3(20) 8(29) 4(44) 1(17) 0(0) 1(50) (100) agement Absent 8(67) 5(71) 3(37) 3(60) 3(75) 12(80) 20(71) 5(56) 5(83) 3(100) 0(0) 1(50)
2 Venting out of Present 9(75) 6(86) 5(63) 4(80) 2(50) 12(80) 22(79) 7(78) 4(67) 1(33) 2(66) (100) emotions Absent 3(25) 1(14) 3(37) 1(20) 2(50) 3(20) 6(21) 2(22) 2(33) 2(67) 1(33) 0(0)
Present 1(8) 0(0) 0(0) 0 0(0) 3(20) 0(0) 0(0) 3(50) 1(33) 0(0) 0(0)
Substance use 11 7 8 5 4 12 28 9 3 2 3 2 Absent (92) (100) (100) (100) (100) (80) (100) (100) (50) (67) (100) (100)
TABLE 4 : USAGE OF COPING STRATEGIES VS CLINIC-DEMOGRAPHIC CHARACTERS-III We then used one way analysis of variance(ANOVA) to find out whether there was any statistical significance in the coping strategies used when assessed across various clinic-demographic variables. The results are shown in table 5. 170 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
TABLE 5: STATISTICAL SIGNIFICANCE OF THE COPING STRATEGIES AS ASSESSED AGAINST VARIOUS CLINICO-DEMOGRAPHIC VARIABLES
P-values of different clinico-demographic variables Coping strategies Marital Past Age Sex Religion Occupation Symptom Stressor Education status History
Active coping 0.491 0.373 0.038 0.667 0.475 0.845 0.889 0.031 0.121
Planning 0.561 0.579 0.218 0.348 0.062 0.665 0.449 0.067 0.007
Acceptance 0.385 0.522 0.845 0.179 0.85 0.399 0.376 0.083 0.646
Suppression of competing 0.652 0.202 0.872 0.472 0.352 0.139 0.404 0.228 0.222 activities
Instrumental 0.415 0.211 0.293 0.24 0.436 0.597 0.359 0.154 0.649 social support
Emotional 0.311 0.309 0.332 0.567 0.566 0.502 0.341 0.007 0.430 support
Behavioural 0.299 0.417 0.454 0.465 0.389 0.161 0.746 0.083 0.163 disengagement
Mental 0.031 0.446 0.077 0.49 0.096 0.434 0.874 0.698 0.500 disengagement
Venting out of 0.624 0.157 0.941 0.386 0.587 0.7 0.443 0.012 0.779 emotion
Substance Use 0.613 0.00 0.367 0.979 0.00 0.456 0.203 0.219 0.427
When the usage of various coping strategies was assessed against age, only the usage of mental disengagement appeared to be statistically significant(P value-0.031). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 171
When assessed across sex, only the usage of the earlier Indian studies[12] which reported conversion ‘substance use’ coping strategy appeared statistically to be commoner among younger adults. About 77% of significant(P value 0.00). our population were literates ,similar to the rates noted in earlier Indian study (80%). [12]However 47% of our The usage of “active coping” as coping strategy was population had at least 10 yrs of formal education(high statistically significant, when assessed across religion(P school passed and above), which is again in contrast to value 0.038),66% of Hindus applied this against 38% of the previous Indian study.[12] Muslims. Hindus accounted for 51% and muslims 49%. Marital status did not affect the coping strategies Religion had a great impact on education(P-value 0.00). used (P-value >0.05 for all strategies). The average age of our population was 30.5 yrs Occupation also did not affect much the usage of and female majority meant most of them were married coping strategies(planning and mental disengagement (68.6%)and were housewives(54%) .This was in contrast came close with P –values close to 0.05).Substance use to a previous Indian study[12] which noted students as the was however significant(P-value 0.0) especially among majority group. However most of other previous Indian semi-skilled workers(50%) and businessmen(33%). studies[11] have noted housewives to be the predominant Planning was least used by housewives(32%) and group. unemployed(50%) compared to others(66-100%) Most common presentation was that of Past history of illness and system involved did unresponsiveness. respiratory symptoms and pseudo not have much bearing on the usage of various coping seizures respectively.This is again in contrast to the strategies(P-value >0.05). previous Indian study[12] which reported pseudo seizure Presence of stressor, however significantly affected as most common(71%) as well as other studies outside [18] the usage of “active coping”(P-value 0.031),”emotional India which reported paresis to be the most common support”(P-value 0.007) and “venting of emotions”(P- presenting symptom. value 0.012).It also affected uses of “planning”, In our population 45% had an obvious stressor ”acceptance” and “behavioural disengagement” also with provoking the episode and a high proportion of married P-values being very close to statistically significant(0.06 people meant that nearly all of them were due to problem to 0.08). with spouse .This is an important finding in the light of Education significantly affected the usage of DSM -5 which has eliminated the need for presence “planning”(P-value 0.007).Most of the illiterates obvious stressor. preferred “venting out” as the strategy(75%) while all Coming to the usage of coping strategies we found other strategies were used less. a that the clinico-demographic variables affected the Age significantly affected the usage of “mental various strategies used in an interesting manner. disengagement” coping strategy. Regarding the problem-focussed coping strategies, Discussions usage of active coping was shaped mostly by stressor,religion(Hinduism) and somewhat by education. We conducted an observational study on 51 The people on the oldest age bracket however preferred consecutive patients of conversion in a tertiary referral to use it,though there was no statistically significant centre in West Bengal for clinic-demographic variables impact of age on usage of active coping. Sex, marital and to study the coping strategies employed by them. status, occupation had little effect on usage of this strategy. In our study females greatly outnumbered males(82.4% vs 17.6%) ,a fact seen in earlier Indian Usage of ‘planning’ was significantly affected by [10][11] studies as well . Most of our patients belonged to education .Thus education appear protective for patients. the age group 35-40 yrs(47%) which is in contrast to 172 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
The coping strategy ‘restraint’ was almost need of treatment. universally rejected. There were some good strategies that were Usage of ‘instrumental social support’ was not universally rejected like restraint, denial, positive significantly affected by the clinic-demographic reinterpretation and growth and humour. variables. Religious coping was universally used as Coming to emotion-focussed coping, ‘religious demonstrated by previous studies.[17] coping’ was the universal strategy irrespective of clinic- demographic variables. Conclusions and Recommendations Our study showed that conversion is a disease Usage of ‘acceptance’ was not significantly of young people, particularly housewives and is quite influenced by any factors. prevalent among literates. Presence of education and Usage of ‘emotional social support’ was greatly employment helps in the development of some adaptive influenced by presence of stressor(P-value of 0.007) problem-focussed and emotion-focussed strategies. while other factors had little impact. However presence of stressor made the people deploy a large number of strategies some of which may be The useful strategies of ‘denial’ and ‘positive harmful. Thus the people with stressor appeared to be reinterpretation and growth’ were unfortunately most vulnerable and in urgent need of treatment. Some universally rejected. useful problem and emotion-focussed coping strategies Coming to the less useful strategies, usage of which were virtually rejected by the people, could be ‘behavioural disengagement’ was not significantly instilled in them to help them adapt better. affected by any variables. Our study was hospital based, cross-sectional ,had Usage of ‘mental disengagement’ was significantly a small sample size and the patients were not followed influenced by age(P-value 0.03) with people in the eldest up. Larger community-based longitudinal studies are group using it the least. needed to identify the maladaptive coping strategies more accurately and also to study the impact of socio- Usage of ‘venting out’ was significantly influenced demographic variables , the analysis of which has so far presence of stressor(P-value 0.012). yielded different results in various Indian studies.
Usage of substance use was heavily influenced by Conflict of Interest: Nil. sex and occupation(p-value 0.00) for obvious reasons. Ethical Clearance: Taken from Institutional Ethical Thus we find the protective influence of education committee and age as it encouraged more use of problem focused coping strategies like active coping and planning and Source of Funding: Self shut out the avoidance coping strategies like ‘mental References disengagement’ or ‘behavioural disengagement’. 1. Saddock Benjamin J , Saddock Virginia A .Kaplan Hindu religion and employment appeared protective and Saddock‘s Synopsis of Psychiatry.10th edition. as they encouraged usage of ‘active coping’ and Lippincott Williams and Wilkin 2007. 609. ‘planning’respectively. This is probably the effect of 2. Diagnostic and statistical manual of mental religion on education(P-value 0.00) disorders. 4th edition, text revision. Washington DC:American Psychiatrists association ; 2000. Presence of stressor was the single most important factor; it seemed to deploy most of the coping strategies. 3. German GA. Aspects of clinical psychiatry in Sub Saharan Africa. Br J Psychiatry. 1972;121:461– But it also brought with it ineffective and potentially 479. dangerous strategies like ‘venting of emotions’ .Thus this group identified as the potential vulnerable group in Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 173
4. Neki JS. Psychiatry in South-east Asia. Br J cases. Indian J Psychiatry. 1986;28:47–49. Psychiatry. 1973;123:257–269. 12. Deka K., Chaudhury P. K. Bora K., Kalita P. A 5. Wig NN, Mangalwehde K, Bedi H, Murthy study of clinical correlates and socio demographic RS. A follow up study of Hysteria. Indian J profile in conversion disorder: Indian Journal of Psychiatry.1982;24:120–125. Psychiatry, 2007;49:205-207. 6. Mahli P, Singhi P. Clinical characteristics 13. Cummings, E. Mark,Greene, Anita L.,Karraker, and outcome of children and adolescents with Katherine H. Life-span Developmental Psychology: conversion disorder. Indian Pediatr. 2002;39:747– Perspectives on Stress and Coping(1991). 92. 752. 14. Lazarus R.S, Folkman S. Stress, Appraisal, and 7. Srinath S, Bharat S, Girimaji S, Sessadri S. Coping (1984).141. Characteristics of a child inpatient population 15. Weiten, W., Lloyd, M.A. 9th edition. Psychology with Hysteria in India. J Am Acad Child Adolesc Applied to Modern Life .Wadsworth Cengage Psychiatry. 1993;32:822–825. Learning 2008. 8. Sridhar MS, Sudharkar TP. Dissociate (Conversion) 16. Carver, C. S., Scheier, M. F., Weintraub, J. K. disorder: Epidemiology and phenomenology Assessing coping strategies: A theoretically based in a general hospital set up. Indian Journal of approach. Journal of Personality and Social Psychiatry. 1997 Apr;39:24. Psychology.1989; 56: 267-283. 9. Diagnostic and statistical manual of mental 17. Vascocelles EB.Religious coping and psychological disorders.5th edition.Washogton DC: American adjustment to stress: a meta-analysis.J Clin Psychiatrists association ; 2000. Psychology 2005 Apr;61(4):461-80. 10. Vyas JN, Bharadwaj PK. A study of hysteria- 18. Roelfs K, Keijsers GP, Hoogduin KA, AN analysis of 304 patients. Indian J Näring GW, Moene FC. Childhood abuse Psychiatry.1977;19:71–74. in patients with conversion disorder. Am J 11. Saxena S, Pachauri R, Wig NN. DSM-III diagnostic Psychiatry. 2002;159:1908-1913. categories for ICD-9 hysteria: A study of 103 174 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13846 The Diagnostic Information Systems: A Pragmatic Approach
Vijay Kumar Tadia Senior Resident Administrator, Department of Hospital Administration, AIIMS, New Delhi
Abstract Introduction: Modern hospitals a manage a large volume of information. Physicians need computers as well as stethoscopes to provide high quality, low-cost, and up-to-date care to patients. The information available helps to make appropriate diagnostic and therapeutic decisions.
Methodology: A descriptive and observational study was conducted at a tertiary care hospital in a metropolitan city of India from April 2012 to December 2012. Purposive sampling was used to select Key Informants (KI). The KIs included the hospital IT Team, hospital administrator and Quality Manager. Semi- structured & Unstructured Interviews were conducted with Key Informants to understand the development of DIS.
Results: The steps involved collection of the User Specific Requirements (URS) and preparation ofa System Design Document (SDD). Different modules were covered in the DIS like Requisition, Generating a memo, Appointments, Sample collection, Department Receiving center, Examination Signal, Reporting, Requisition status, MIS Queries The DIS was designed under client/server environment. System indicated a uniform method of reporting error messages.
Discussion and Conclusion: The Diagnostic Information System enabled the hospital to put in place various diagnostic services e.g., pathology including surgical pathology, cytology, transfusion medicine including blood banking, diagnostic endoscopy and cardiology including ECG, etc. With the implementation of this system, the diagnostic reports were made available on the clinician’s desktop as soon as the investigations were reported. Thus, the turnaround time had been considerably reduced. The problem of misplaced reports had almost been eliminated due to this. The MIS reports, both operational and executive, were a positive outcome of the system.
Key Words: Diagnostic Information System, User Specific Requirements, System Specific Requirements (SRS)
Introduction important for efficient patientcare.2 The sharing of diagnostic data among hospitals and providers and Modern hospitals a manage a large volume of the potential to significantly reduce patient mortality information. Physicians need computers as well as and readmissions.3-5 A lot of studies have shown the stethoscopes to provide high quality, low-cost, and benefits of Hospital Information Systems and Diagnostic up-to-date care to patients. The information available Information Systems are a subset of that.6-10. In 1979, helps to make appropriate diagnostic and therapeutic after years of professional frustration with manual and decisions.1 The communication of diagnostic data is automated systems, a practicing internist analyzed the problem and decided to develop a simple solution, the Corresponding Author: Diagnostic Information System® (DIS). 1 Dr. Vijay Kumar Tadia Many of the problems encountered diagnostic Senior Resident Administrator Department of Hospital Administration systems stem from poorly written specifications. AIIMS, New Delhi The development of successful diagnostic systems Email: [email protected] is predicated on the user’s identifying valid system Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 175
requirements and accurately articulating these Modification/Hold/Updating routine. requirements, via specifications, to the contractor. This · Reports, the reporting frequency, contents of paper identifies important considerations in developing the reports, compilation logic, users of the report, input- user requirements and presents an approach to diagnostic output linkages. specifications for future systems.11 This URS report formed the blueprint of the final Methodology hardware and software configurations. The software was A descriptive and observational study was conducted developed as per URS. at a tertiary care hospital in a metropolitan city of India from April 2012 to December 2012. Purposive sampling Preparation of a System Design Document (SDD): was used to select Key Informants (KI). The KIs included The step after URS preparation was to make a detailed the hospital IT Team, hospital administrator and Quality and technical SDD. Data that was collected from the Manager. Semi-structured & Unstructured Interviews URS was analyzed and then used. The following were were conducted with Key Informants to understand the the issues tackled in the SDD. development of DIS. · Screens with edit checks, attribute sheets, method of accepting data and its storage. Results Diagnostic Information System (DIS): The need · Report formats with process sheets for their of timely information regarding diagnostic results, mode of retrieval. availability of equipment and consumables could not · Database file structures. be over emphasized. All the labs were connected to the Hospital Wide Network, which enabled the sharing of · Data flow diagrams. data and with the rest of the hospital. Facilities were · Processes and their logic. being provided to record and project investigations for live display in the hospital auditoria. Research was an · Inter-relationship between various processes. integral part of the culture at hospital. It was imperative that clinicians should be able to retrieve patient care · Security features. details swiftly and accurately. · Recovery procedures of backups. Collection of the User Specific Requirements With the blueprint of URS and the SDD in hand, the (URS): This was the first step in the process of the actual process of implementation of DIS took off. development of DIS. The URS were converted to the System Specific Requirements (SRS). The stakeholders Aims and Objectives of the system: involved in the process were given a URS questionnaire for the inputs. The contents of URS included; § Raising the requisition from any terminal in the hospital. · Data Flow Diagrams with brief description covering activities, sub-activities, linkages, input, and § Documentation for the requisition. output in a schematic form giving interfaces and inter § Generation of Memos for Billing. linkages with other systems. § Collection of Samples. · Coding Structure and Logics giving the structure of each element that needed to be coded in the system. § Receiving of the samples in the Departments.
· Input/Screen Formats covering; Functional § Testing the Samples in the respective description, Screen level information giving description departments. of each & every field, Field level checks & controls, § Recording the preliminary and finalized reports. Authorization and security checks for each of the forms, 176 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
§ Integration with the Electronic Medical Record instructions were specified for each service specified in and Discharge Summary. the requisition.
Modules of the DIS: The following modules were Sample Collection: covered in the DIS: In sample collection centre, technicians collected § Requisition the samples and sent them to the respective departments. The collection centre in which the sample was collected, § Generating a memo the department and modality to which the sample would § Appointments be sent, and the case number of the patient whose sample was collected were noted down. In sample § Sample collection collection centre, all the requisitions whose memos had been paid were displayed. As and when the sample was § Department Receiving center collected, the corresponding requisition was ticked by § Examination Signal the technician.
§ Reporting Sample Receiving Centre received the samples and an internal number was generated. The requisition § Requisition status number was ticked in the receiving department.
§ MIS Queries Examination completion signal was generated by Requisition: ticking the corresponding requisition number.
Requisition for a particular test for a patient was Reporting was done by the concerned doctor/ raised on the advice of the concerned doctor. Each pathologist. All the observations were marked and requisition was attached to a unique Requisition number. Preliminary report for each examination done was written The requisition number indicated the Department by the doctors after seeing the examination details. The and Modality in which the test had to be conducted, examination details were available, and the preliminary the year in which the requisition was being generated report was entered which was immediately available for and the serial number of the test in that year. Also, a the authorized person to finalize. The finalized reports Pathology number (Path number) was generated for all were printed and attached to the case file. the pathology tests that were requested. One requisition Requisition status: The status of any requisition number could be used for conducting more than one could be found out from anywhere in the hospital examination in a department for Microbiology and through the on-line system. Biochemistry requisitions. The status of all the requisitions between two given Memo Generation: dates or the requisitions of a specific case number could Memos were generated for all the raised be found. The status indicated the stage of the requisition, requisitions. The memos indicated the amount to be paid which could be Appointment, Memo generated, Payment to the hospital for each service requested. The outpatient paid, Sample Collected, Sample Received, Report memos were generated for outpatients and could be paid Written and also Path Number if allotted. individually. The inpatient memos were generated for MIS Queries were generated to list the details of all admitted patients and were included in final or interim the patients for whom requisitions were raised between bill. given dates, Surgical Pathology Reports generated Appointments: between given dates, Referral cases and Doctor Wise details of the requisitions. Appointments were issued for each requisition raised for the patient. The date, time, location and the Flow chart of the Diagnostic Information System Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 177
Requisition for Investigation
In Patients Free Patients
Memos
Out Patients Receipt Sample Collection Centre
Department Receiving Centre
Carrying the
Investigations
To Electronic Medical Report Generation Records (Directly)
Sending the Reports to Wards/ICU
Figure 1. Flow chart of the Diagnostic Information System
Functional Requirements: database.
All the screens were designed as per the following Answer back panel was the panel where respective Standard Architecture: data would be displayed from related database tables on receiving the “KEY FIELD”. a) Initial panel and Answer back Panel: The Initial Panel would be used to key in a “KEY FIELD” b) Entry Panel: Entry panel was the panel in so that Linked Data / Basic could be retrieved from the which the user would enter the information. Tool tip 178 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
help could be provided when the mouse moved to the · DB2/400 specific field. · OS/400 c) Command Panel: Command panel was the · Windows panel where user would give the instruction for next operation. Tool tip help could be provided when the · MS Office mouse moved to the specific button. · VB 6.0 d) Message Box: This box would display the help messages related to the field where the cursor · VB.Net was positioned. The message box would also provide Performance of the DIS: messages as appropriate such as: The DIS was designed under client/server i) New record successfully added environment. To determine the number of users, for ii) New record could not be added a reasonable response, the Hardware and Software configuration at server and node was considered. The iii) Record successfully modified Server could handle around 400 terminals initially. Initially the volume of transactions was expected to iv) Record could not be modified be less, but on usage the volume could be high. The v) Record deleted recommended hardware and system software could handle a minimum TPC rating of 1200 per minute. vi) Record cannot be deleted System indicated a uniform method of reporting vii) Record committed error messages. viii) Record commitment failed Performance of the DIS depended on the ix) Printing completed following factors:
x) Printing error · Number of users
xi) Transaction could not be saved · Number of records that can be handled
xii) Last transaction cancelled · Volume of transactions
Hardware and Software requirements: · Response time
In order to have a meaningful system, the following · Background and batch processing time Hardware & Software environment was maintained. · Error handling procedures Client/Server Environment: A Centralised Security Features: Database Server existed to cater to the various requirements. Clients at all the sections got connected to Appropriate security and control: The Systems the Centralized Server over Ethernet and co-axial lines would provide adequate security and control features to gain the advantage of distributing an application. such as
Hardware Requirements: · Password and Security for operational, middle and top management level. · AS/400 Machine · Control of user access to applications (read · 12 Nos. Of Pentium nodes in a network. only, write only, read and write) Software Requirements: · Data Integrity Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 179
· Disaster recovery for operations such as insertion, viewing, modification, saving, cancelling, exiting etc. wherever applicable. · Audit trail features · A uniform graphical user interface was provided Data Protection and Security: The system for all the screens which facilitated easy learning and provided data protection to guard against loss of data. user friendliness. These features were provided by Other Features: Database backup/Recovery · Easy backup and retrieval procedures and utilities were made available to the · Data maintenance in the file say for a period of System Administrator. To backup database hospital was 24 months, normally using BRMS (Backup, Recovery and Media Services) System. · Data carry forward while creating the file or period end process for the next year or for a new period Discussion & Conclusion
· Transfer of annual data into separate file for The Software Requirement Specification (SRS) preservation of the data on a long-term basis. described in detail the requirements of DIS at the hospital. All functional and other requirements were User Characteristics: discussed. The SRSs were prepared based on mutual discussions and continuous interaction between hospital The systems were user friendly, menu driven, since officials & developer and it formed the basis for design. they would be used directly by users, some of whom did not possess specialized information technology skills. The Diagnostic Information System enabled the The user-friendly features viz. List of values, structured hospital to put in place various diagnostic services querying etc., were provided. e.g., pathology including surgical pathology, cytology, transfusion medicine including blood banking, The intended users were classified as: diagnostic endoscopy and cardiology including ECG, · Operational level users etc. With the implementation of this system, the diagnostic reports were made available on the clinician’s · Middle level management users desktop as soon as the investigations were reported. Thus, the turnaround time had been considerably · Top level management users reduced. The problem of misplaced reports had almost · Security level users been eliminated due to this. The MIS reports, both operational and executive, were a positive outcome of The users were expected to have computer the system. In addition, the interfacing of analytical awareness and were trained to use the application. equipment like biomedical analyzers and cell counters System Administrators were expected to possess the with the diagnostic information system had reduced the Knowledge of OS/400, RDBMS concepts, Application lead-time of reporting and had eliminated transcription Administration and also thorough knowledge of the errors tremendously. application and the requirements of their departments. The study was not funded by any agency and was General features an academic activity carried out during the Masters · The system was on-line and integrated. in Hospital Administration under the guidance of co- authors. · Highly user-friendly and menu-driven Ethical Clearance: No need · Data was captured at source and would be complete and accurate. Source of Funding: Self
· Every screen contains title and standard buttons Conflict of Interest: Ni 180 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Acknowledgement: The study was not funded by and its effects on hospital costs, outcomes, and any agency and was an academic activity carried out patient safety. Inquiry. 48(4):288–303. during the Masters in Hospital Administration. 6. Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, et al. Can electronic medical Ethical Clearance: No need record systems transform health care? Potential Source of Funding: Self health benefits, savings, and costs. The adoption of interoperable EMR systems could produce Conflict of Interest: Nil efficiency and safety savings of $142-$371 billion. Heal Aff. 2005;24(5):1103–17. References 7. Wang SJ, Middleton B, Prosser LA, Bardon CG, 1. Coli RD. The diagnostic information system: a Spurr CD, Carchidi PJ, et al. A cost-benefit analysis new tool for accurate medical decision-making. of electronic medical records in primary care. Am J Looking for the solution without understanding the Med. 2003 Apr 1;114(5):397–403. problem is working in the dark. R I Med J. 1983 8. Frisse ME, Holmes RL. Estimated financial savings Oct;66(10):411–5. associated with health information exchange and 2. Solet DJ, Norvell JM, Rutan GH, Frankel RM. ambulatory care referral. J Biomed Inform. 2007 Lost in translation: challenges and opportunities Dec;40(6 SUPPL.). in physician-to-physician communication 9. Shekelle PG, Morton SC, Keeler EB. Costs and during patient handoffs. Acad Med. 2005 benefits of health information technology. Evidence Dec;80(12):1094–9. report/technology assessment. 2006. p. 1–71. 3. Jones SS, Adams JL, Schneider EC, Ringel JS, 10. Kian LA, Stewart MW, Bagby C, Robertson J. McGlynn EA. Electronic health record adoption Justifying the cost of a computer-based patient and quality improvement in US hospitals. Am J record. Healthc Financ Manage [Internet]. 1995 Manag Care. 2010 Dec;16(12 Suppl HIT):SP64-71. Jul [cited 2020 Jan 26];49(7):58–60, 62, 64–7. 4. Wayne JD, Tyagi R, Reinhardt G, Rooney D, Available from: http://www.ncbi.nlm.nih.gov/ Makoul G, Chopra S, et al. Simple standardized pubmed/10143674 patient handoff system that increases accuracy and 11. Carroll WH, Linden VL, Waldo CR. Diagnostic completeness. J Surg Educ. 2008;65(6):476–85. Specification-A Proposed Approach. IEEE Trans 5. Encinosa WE, Bae J. Health information technology Reliab. 1981;R-30(3):227–31. DOI Number: 10.37506/ijphrd.v12i1.13847 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 181 Challenges of Rural Healthcare Infrastructure: A Study among North-Eastern States of India
Manuranjan Gogoi1 , Sarat Hazarika2, Khirod Kr. Phukan3, Purabi Gogoi4 1Guest Faculty, Department of Economics, Madhabdev University, Narayanpur, Assam, 2Registrar i/c, Madhabdev University, Narayanpur, Assam, 3Assistant Professor, Department of Economics, Madhabdev University, Narayanpur, Assam, 4Assistant Professor, Department of Economics, T.H.B. College, Jamugurihat, Sonitpur, Assam
Abstract Health service is very important for the socio-economic upliftment of a country. Every citizen of a nation wants a better healthcare service to maintain their hygienic life. In India there is always facing a shortfall of healthcare services mainly in rural areas of the country. Therefore, the present study is trying to examine the current status of rural healthcare infrastructure of the nation especially in the North-Eastern Region (NER) of India i.e. the states Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Tripura and Sikkim. It also aims to make a comparative analysis of healthcare infrastructure among NER states. The study is solely based on secondary data and collected from different sources of Government of India.
Keywords: rural healthcare infrastructure, Challenges of Healthcare, North-East India
Introduction 2002). There is a vast change seen in the twenty first century in India, but still the nation is deprived for its Health is one of the most important indicators of infrastructure development as compared to other nations human development index after Education and standard of world. Mainly the country still poor for its health of living (UNDP). A good health not only provides a sector compared with other developing countries of Asia hygienic life but also provides better work efficiency i.e. China, Sri-Lanka and Bangladesh. In the sense of in the labour market. The growth of the health care health indicators like infant mortality, life expectancy infrastructure is important for its enhancement of of birth, mortality under age five, India is still poor economic development of a nation. According to compared with the countries that mentioned above (WHO, 2000) for a very long time, the main objective (GOI, 2005). For the development of health status of the of most of the developing countries is to develop citizens of the country there is a need of adequate health the health status of their citizens. In a broad sense, it care infrastructure. According to Rural Health Statistics is a contributor of enhance the expectancy of life and (RHS) 2018-19, Govt. of India, the total number of Sub economic participation that leads to alleviation of Centres (SCs) is 160713 (157411 rural + 3302 urban) and poverty of a region. they are functioning. Similarly, 30045 Primary Health For any economic activities infrastructure is Centres (PHCs) is functioning in India (24855 rural necessary. So, it is defined, Infrastructure is the social + 5190 urban) and there are 5685 Community Health capital or basic services of a country which make Centres (CHCs) (5335 rural + 350 urban) functional in possible economic and social activities (Rutherford, the country. But the current numbers of SCs, PHCs & CHCs are not as per IPHS norm.
Corresponding author: Data Source Manuranjan Gogoi The paper based on secondary data only. Data has Email: [email protected] been collected from different source such as Rural Health Phone: +919859471709 182 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Statistics (RHS)- 2018-19 published by Government of is happen in case of rural birth rate also, but only urban India Ministry of Health and Family Welfare Statistics birth rate of all the states of north-east is lower than all Division, SRS Bulletin published by Office of The India level (16.8). In case of death rate, total death rate Registrar General, India, India HIV Estimates 2019 of Assam (6.5) is higher than all India level (6.3). On Report, published by National aids control organization, the other hand rural death rate of all the states of NER is ICMR – National Institute of Medical Statistics, Ministry better position in all India level (6.9) but in case of urban of health & family welfare government of India and death rate the states Assam and Manipur are in the same Database of Government of India (https://data.gov.in). position with all India level (5.3) and the remaining six states are quite better positions than all India level. Present Health Status of North-East India Natural growth rate of Assam and Meghalaya is greater The rural health care infrastructure of NER of than national average also the same condition in the rural India is still weaker than the states of the country. sector. But in urban NGR of Sikkim (14.9) is greater But after implementation of NRHM, in 2005 there than all India average (11.6). In case of IMR the states is a significant improvement seen in the region for its Assam, Arunachal Pradesh and Meghalaya is shown the healthcare infrastructure (Saikia, 2014). To analyze the higher IMR than all India level(33) but the IMR of the current health status of NER, India the study focused on remaining states is quite good than all India average. four indicators like- Birth Rate (BR), Death rate (DR), The state Nagaland is the most favored sates with lowest Natural Growth Rate (NGR) and Infant Mortality Rate IMR (7) among all the states of NER, India. The rural (IMR) of the region. The following table 1 shows the IMR of Assam, Arunachal Pradesh and Meghalaya is four indicators that presented separately and categorized also higher than all India average, but in case of urban each of the indicators like- Total (T), Rural (R) and IMR the states Arunachal Pradesh, Meghalaya and Urban (U). Total Birth rate of Assam and Meghalaya Tripura is in bad position than all India average. It is also is more than of national level (India). The same result mentionable that, the rural IMR (37) of India is higher than urban IMR (23), resulted an inadequate health infrastructure of rural India.
Table 1: Estimated Birth rate, Death rate, Natural growth rate and Infant mortality rate, 2017
NGR IMR BR DR States T R U T R U T R U T R U
Arunachal Pradesh 18.3 18.8 15.5 6.1 6.4 4.9 12.1 12.4 10.6 42 44 34
Assam 21.2 22.4 14.7 6.5 6.7 5.3 14.7 15.7 9.4 44 46 21
Manipur 14.6 14.8 14.1 5.3 5.3 5.3 9.3 9.5 8.8 12 13 9
Meghalaya 22.8 24.8 13.7 6.1 6.3 4.8 16.7 18.5 8.8 39 41 25
Mizoram 15.0 17.7 12.2 4.0 4.0 4.1 11.0 13.8 8.0 15 20 7
Nagaland 13.5 14.0 12.7 3.6 4.2 2.7 9.9 9.8 9.9 7 7 7
Sikkim 16.4 15.2 18.3 4.5 5.3 3.4 11.9 9.9 14.9 12 13 9
Tripura 13.0 14.1 10.3 5.2 5.2 5.2 7.8 9.0 5.1 29 28 32
India 20.2 21.8 16.8 6.3 6.9 5.3 13.9 15.0 11.6 33 37 23 Note: Infant mortality rates are based on three-year period 2015-17. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 183
Source: SRS Bulletin, Office of The Registrar Another serious health problem not only for North General, India East India, but also the problem of whole world is Acquired Immune Deficiency Syndrome (AIDS) disease. The health status of North-East India cannot be Still there are no proper medicines invented of this equally treated as shown in the table 1. This is because of disease to curing it. Just only few preventive measures the inadequate development of the health infrastructure and active awareness among citizens can reduce it to or its unavailability of adequate manpower in the health spreading the disease. The present scenario of AIDS sector. Poor conditions of health infrastructure of the mortality of North-Eastern states and other Indian states/ country means, there is a problem of non-availability of UTs represents the figure 1 below- free medicines for rural poor, non-availability of good doctors and lack of sufficient number of government hospitals in rural areas of the country (Das, 2012).
Figure 1: AIDS Mortality by State/UT, 2019 (per 100,000 population)
Source: India HIV Estimates-2019, Govt. of India the figure; the states Assam (1.67), Arunachal Pradesh (1.14), Sikkim (0.64) and Tripura (0.46) are somewhere Figure 1 shows, AIDS related mortality of India is in better position and below the level of all India at 4.43 per 100,000 population in India. average (4.43). India HIV Estimates report 2019 also State wise AIDS related mortality of per 100,000 mentioned that, the HIV-AIDS detected persons are population, the three north-eastern states estimated to be gradually increasing all over the country. So it is a major in highest position all over India i.e. – Manipur (36.86), concern for all human being. In this regards there is a Mizoram (28.34) and Nagaland (26.2). This means need of sufficient health infrastructure in the region as inadequate health awareness of AIDS disease among well. the citizens of the states. Similarly, Meghalaya (11.08) Healthcare Infrastructure of North-East India is also in fifth position after Andhra Pradesh (21.76) and Pondicherry (15.33). On the other hand, it is reflected in The healthcare infrastructure in rural areas of India 184 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 has been developed as a three tier system i.e. - Sub situated in village level and they are nearest from the Centres (SC), Primary Health Centres (PHCs) and households. For critical cases people preferred to go Community Health Centres (CHCs). These three are the CHCs those are located mainly in semi-urban areas. The common health infrastructure of rural society. Mainly following table 2 shows the rural population and average SCs and PHCs are the first and foremost choice of health rural population covered by the health sector in NER. care among the rural civilian. Because these centres are
Table 2: Average rural population covered by SCs, PHCs and CHCs
Average Rural Population [mid- Estimated mid- year population as on 1st July 2019] year Population Sl. Rural Population covered by a State 2019 (as on 1st No 2011 Census July 2019) in Rural Areas SC PHC CHC
1133000 1 Arunachal Pradesh 1066358 (77.06)* 2,943 7,923 17,984 (75.18)*
26807034 2 Assam 29208000 (84.88)* 6,291 30,875 1,65,017 (75.90)*
2132000 3 Manipur 2021640 (70.79)* 4,351 23,689 92,696 (68.53)*
2569000 4 Meghalaya 2371439 (79.93)* 5,386 21,771 91,750 (79.48)*
525435 547000 5 Mizoram 1,478 9,271 60,778 (47.88)* (45.77)*
1281000 6 Nagaland 1407536 (71.17)* 2,958 10,167 61,000 (59.44)*
456999 389000 7 Sikkim 2,210 13,414 1,94,500 (74.84)* (58.49)*
2595000 8 Tripura 2712464 (73.83)* 2,670 24,028 1,44,167 (64.84)*
833748852 884021000 9 India 5,616 35,567 1,65,702 (68.85)* (66.09)*
Note; *: Percentage share of population to the total population.
Source: Rural Health Statistics 2018-19, Govt. of India
Table 2 shows the rural population of all the NE states in the year of 2011 and 2019. It also shows the average number of population covered by the health services of those states. In case of SCs only Assam is in better position than the national average. Similarly, the conditions of PHCs of all the NE states are very poor and it was lower than national average. On the other hand, in case of CHCs only Sikkim is in better position than national average. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 185
Challenges Faced by the Rural Healthcare position than the other states of India. Some of the states Infrastructure of North-East India of the region do not have adequate number of SCs, PHCs and CHCs in the rural areas. The following table Position of SCs, PHCs and CHCs 3 is trying to show the present status of rural healthcare Rural healthcare services of North-eastern states centres in the North-eastern states of India. of India facing many problems since many decades but in some aspects the states of the region are in a good
Table 3: Shortfall of SCs, PHCs and CHCs as per estimation of mid-year population (as on 1st July 2019) in rural areas of North-East India
Estimated SCs PHCs CHCs midyear States population for Rural areas R P S R P S R P S
Arunachal 1133000 338 385 + 51 143 + 12 63 + Pradesh
Assam 29208000 6374 4643 1731 1040 946 94 260 177 83
Manipur 2132000 537 490 47 84 90 + 21 23 +
Meghalaya 2569000 822 477 345 124 118 6 31 28 3
Mizoram 547000 179 370 + 27 59 + 6 9 +
Nagaland 1281000 414 433 + 62 126 + 15 21 +
Sikkim 389000 96 176 + 15 29 + 3 2 1
Tripura 2595000 661 972 + 104 108 + 26 18 8
All India/ 874021000 189765 157411 43736 31074 24855 8764 7756 5335 2865 Total
Notes: The requirement is calculated using the prescribed norms on the basis of rural population estimation for mid- year for the year 2019.
R: Required; P: In Position; S: Shortfall; +: Surplus its population and shown a shortfall of rural SCs 1731, 47, 345 respectively. But the state Arunachal Pradesh, Source: Rural Health Statistics 2018-19, Govt. of Mizoram, Nagaland, Sikkim and Tripura have surplus India SCs. Similarly, Assam and Meghalaya has a shortfall Table 3 shows the SCs in rural areas of Assam, of rural PHCs 94 and 6 respectively but the other states Manipur and Meghalaya still inadequate with the size of of NER have in better position with surplus values. In case of CHCs, the states Assam, Meghalaya Sikkim and 186 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Tripura is facing a problem of unavailability of sufficient services. The states of North-East are in a good position community health centres. From this analysis it is for its female health workers/ ANMs in rural SCs accept noticeable that, the state Assam and Meghalaya have a Sikkim and Tripura. There is a shortfall of 24 and 388 shortfall of all three types healthcare infrastructure in the of these two states. But the other states of the region are rural areas of those states. In case of Assam, an analysis having surplus female workers in SCs of rural areas as has been given by (Buragohain, 2015) that, health status per IPHS norms (RHS, 2018-19). In case of male health of the rural areas is poorer than the urban areas. In case worker in rural SCs there is a huge deficiency (98063) of all India level, there is also a huge shortfall seen in shown all over the country including NER. Similarly, the all three categories. It is implies that, the health availability of doctors, health workers in PHCs is also infrastructure of the country still inappropriate. very important. Because, the people of rural areas preferred the PHCs as their first choice if they facing Status of manpower in rural healthcare services general health related problems. The following Table 4 Healthcare infrastructure will not be sufficient if shows the present status of rural PHCs of NER in terms the adequate manpower is not available to provide the of their availability of doctors and other health workers as per IPHS norms.
Table 4: Availability of Doctors and other health workers in rural PHCs of NER (As on 31st March, 2019)
Shortfall Shortfall Shortfall Shortfall Shortfall Shortfall of health of Health Shortfall of Health of of States of worker assistants of assistant Laboratory Nursing Doctors [female] / [female] / Pharmacists ANM LHV [male] Technicians Staff
Arunachal 27 + 126 62 88 93 + Pradesh
Assam + + 694 946 + + +
Manipur + + 26 90 + 39 +
Meghalaya + + 11 21 + + +
Mizoram + 33 40 37 11 + +
Nagaland + + 126 126 32 52 +
Sikkim + + 12 16 16 0 +
Tripura + 28 108 102 + 11 + Note: calculated as per IPHS norms, +: Surplus
Source: Rural Health Statistics 2018-19, Govt. of India
As per IPHS norms there is a one doctor, one female each PHC. Table 4 shows, surplus doctors are available health worker/ANM, one Health Assistant [Female] / in rural PHCs of all the states of NER accept Arunachal LHV, one Health Assistant [Male], one pharmacist, one Pradesh. Similarly, two states Mizoram and Tripura have laboratory technician, one nursing stuff is necessary for insufficient female health worker/ANM in their rural Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 187
PHCs but the other states of NER have surplus female nursing stuffs are available in all the states of NER, health worker/ANM. In case of health assistant (Male shown by (RHS 2018-19). It is a positive sign for rural and Female), there is a huge shortfall in every states of healthcare service in the region. the region which means violation of IPHS norms. On The role of CHCs is very significant for rural people the other hand the states Arunachal Pradesh, Mizoram, of the country. During a serious disease or other serious Nagaland and Sikkim facing a shortage of pharmacists health related problems, people of the rural areas prefer in rural PHCs as per IPHS norms. Similarly, Arunachal the CHCs. The present situation of CHCs on the basis Pradesh, Manipur, Nagaland and Tripura are facing of availability of manpower in NER is shown in the the problem of insufficient laboratory technicians in following table 5. rural PHCs. It is also mentionable that there are surplus
Table 5: Availability of Doctors and other health workers in rural CHCs of NER (As on 31st March, 2019
Manpower in CHCs of NE States (As on 31st March, 2019)
Shortfall of Shortfall of Shortfall General Shortfall Total Specialists Shortfall of States of Duty Shortfall of Shortfall of of [Surgeons, Laboratory AYUSH Medical Radiographers at Pharmacists Nursing OB&GY, Technicians Doctors at Officers CHCs at CHCs Staff at Physicians & at CHCs CHCs (GDMOs) CHCs Paediatrician] - Allopathic
Arunachal 7 248 11 46 17 0 + Pradesh
Assam 91 572 + 87 + + 47
Manipur + 89 + + + + +
Meghalaya 5 108 + 10 + + +
Mizoram 3 36 3 4 1 + 12
Nagaland 0 76 9 18 + + +
Sikkim 0 8 0 + 0 + +
Tripura 2 70 + 7 + + + Note: calculated as per IPHS norms, +: Surplus
Source: Rural Health Statistics 2018-19, Govt. of Physicians and Pediatrician) in rural CHCs. On the other India hand, Arunachal Pradesh, Mizoram and Nagaland have inadequate number of General Duty Medical Officers- Table 5 shows only Manipur has the surplus AYUSH Allopathic. In case of radiographers in rural CHCs, only doctors, Nagaland and Sikkim has also adequate numbers. Manipur and Sikkim has the surplus numbers. There is But the other states of the region have not adequate a shortfall of pharmacists shown in case of Arunachal number of AYUSH doctors in their CHCs located in the Pradesh and Mizoram. In case of Laboratory technicians rural areas. Similarly, in all the states of the region has a all the states of NER have adequate number of manpower shortfall of total specialist doctors (Surgeons, OB & GY, 188 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 and it is a positive sign for health sector of the region. Building position of SCs: According to RHS 18- But at the same time, Assam (47) and Mizoram (12) has 19, Arunachal Pradesh, Mizoram and Sikkim has the a shortfall of nursing staffs of rural CHCs. adequate number of government buildings. On the other hand there is a deficiency of government buildings in other Status of building positions of health sector in NER the states of NER accept these three states. Assam has Basic infrastructure facilities are necessary to the highest deficiency of buildings and required around provide good health services among citizens. In the 594 buildings. This is resulted in Assam; a government north-Eastern states the basic infrastructure facilities of package is required to construct new buildings in rural rural health sector are not very well but comparatively areas mainly for SCs. The following table 6 shows the better in some states than other states of the country. current building position of SCs in NER. One of the basic infrastructures is building facilities. The current status of building facilities in rural health sector discussed below.
Table 6: Building position of SCs in rural areas of North-East India
Sub-Centres
Total Buildings Number Buildings required States Under of Sub Rent Free to be constructed Construction Centers Govt. Rented Panchayat / Builidings Buildings Vol. Society Buildings
Arunachal 385 385 0 0 0 0 Pradesh
Assam 4643 4049 466 128 0 594 Manipur 490 459 31 0 18 13 Meghalaya 477 468 2 7 0 9 Mizoram 370 370 0 0 0 0 Nagaland 433 316 1 116 59 58 Sikkim 176 175 1 0 1 0
Tripura 972 810 28 134 17 145 Notes: Required number of building to be constructed = Total functioning - (Government Buildings + Under construction) (ignoring States having excess.)
Source: Rural Health Statistics 2018-19, Govt. of India
Building position of PHCs: As per rural health statistics 2018-19, accept Nagaland all the states of north east India has the sufficient number of building in rural states there is a sufficient number of PHC buildings PHCs. There is a shortfall of building only in Nagaland are available, even there is an additional building is and it was 7 only. Overall the north eastern states are in a available in Tripura (RHS 2018-19). It implies that, better position in case of buildings of their PHCs. basic infrastructure facilities in case of buildings all the states of NER are in a better position. Building position of CHCs: In all the North-Eastern Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 189
Findings & Conclusion • SC : Sub Centre
The study attempted to examine the current status of • UNDP : United Nations Development rural healthcare infrastructure of North-Eastern Region Progamme of India in terms of birth rate, death rate, natural growth rate and infant mortality rate. Though it is found that • WHO : World Health Organization rural death rate of all the states of NER is lower than all Acknowledgement : Nil India level, but in case of other indicators, it is not good. . It also discussed a serious health disease called AIDS Ethical Clearance : Taken and its current status on NE States through mortality Self rate and found this is a serious health issue for this Source of Funding : region. Similarly, in case of healthcare infrastructure Conflict of Interest : Nil of NER, almost all the states of north east India are lacking better condition of SCs, PHCs as compared to References the national average. Some of the states of this region 1. Buragohain P.P. Status of rural health infrastructure do not have adequate number of SCs, PHCs and CHCs of Assam. International Journal of Management particularly in rural areas. It has also shortfall in terms of and Social Science Research Review, 2015, 1(15), availability of doctors, nursing staffs etc. which needs to 210-218. be increased with proper training. The study found that 2. Das S. Rural Health Status and Health Care in the improvement of health care infrastructure in NER North-eastern India: A Case Study. Journal of of India is unequal and therefore it is unsatisfactory. Health Management, 2012, 14(3), 283–296. There is an urgent need to take some policies by the 3. GOI. Report of the National Commission on government to establish some new SCs, PHCs in rural Macroeconomics and Health, Ministry of Health parts of north eastern region of India and also the existing and Family Welfare, Government of India, 2005. infrastructure needs to be improved through increasing 4. India HIV Estimates 2019 Report, National Aids the number of health workers with proper train. Control Organization | ICMR – National Institute Abbreviations: of Medical Statistics Ministry of Health & Family Welfare, Government of India. • ANM : Auxiliary Nurse Midwife 5. Lyngdoh L M. Inter-State Variations in Rural Healthcare Infrastructure in North-East India. The • AYUSH : Ayurveda, Yoga & Naturopathy, NEHU Journal, 2015, 13 (2), 31-48. Unani, Siddha and Homoeopathy 6. Mal S, Bhattacharya P, Ghosh B. Consequence • CHCs : Community health Centre of health infrastructure of north east India in comparison with India. Radix International Journal • GOI : Government of India of Research in Social Science, 2013, 2(7), 1-14.
• ICMR : Indian Council of Medical Research 7. National Family Health Survey (NFHS-4) India, 2015-16, Ministry of Health and Family Welfare, • IPHS : Indian Public Health Standards Government of India. 8. Paul P K, Jana S K, Maiti A. An Analysis of Health • LHV : Lady Health Visitor Status of the State of Assam, India. Research • NE : North- East Review International Journal of Multidisciplinary, 2019, 4(9), 1179-1188. • NER : North-Eastern Region 9. Rutherford D. Dictionary of Economics. Second Edition. Routledge. London and New York, 2002. • NRHM : National Rural Health Mission 1. Rural Health Statistics 2018-19, Government • PHC : Primary Health Centre of India Ministry of Health and Family Welfare Statistics Division. • RHS : Rural Health Statistics 190 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
10. Saikia D. Health Care Infrastructure in the Rural 12. SRS Bulletin, Sample Registration System, Office Areas of North-East India: Current Status and Of The Registrar General, India Vital Statistics Future Challenges. Journal of Economic & Social Division, West Block 1, Wing 1, 2nd Floor, R. Development, 2014, 10 (1), 83-99. K. Puram, New Delhi-110 066, Volume 52 No.1, 11. Saikia, D. and Das, K.K. Rural Health Infrastructures May, 2019. in the North-East. http://mpra.ub.uni-muenchen. 13. The World Health Report .2000. Health de/41859/, 2012. 1-10. Systems: Improving Performance, World Health Organization. DOI Number: 10.37506/ijphrd.v12i1.13848 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 191 The Effect of Fibrin Glue Application as a Sealant in Protecting Colon Anastomosis with Continues Suture Compared to Simple Interrupted Suture in Intraperitoneal Infection Condition Measured by Tissue Hydroxyproline Level (Wistar Rat Study)
Agung Fuad Fathurochman1, Vicky Sumarki Budipramana2, Jusak Nugraha3 1Resident of Surgery, Faculty of Medicine Airlangga University - Soetomo General Hospital Surabaya, 2Staff of Digestive Surgery Division, Department of Surgery, Faculty of Medicine Airlangga University - Soetomo General Hospital Surabaya, 3Staff of Department of Clinical Pathology, Faculty of Medicine Airlangga University - Soetomo General Hospital Surabaya
Abstract Background: Anastomotic leakage is a serious complication in gastrointestinal surgery, especially in peritonitis condition. Simple interrupted suture is the gold standard for intestinal anastomosis; however, it has a greater risk of contamination by peritoneal fluid. Fibrin glue has been used as a barrier to protect the intestinal anastomotic suture by increasing hydroxyproline levels. But its benefit in continuous suture is still debatable.
Objective: To determine the effect of fibrin glue as a sealent in protecting colon anastomosis with continuous suture compared to simple interrupted suture in intraperitoneal infection conditions.
Method: In this experimental study, the rats were divided into two groups: control group (Groups 1 and 2) and experimental group (Groups 3 and 4). Group 1 and 3 were performed by simple interrupted, while the others by continuous suture. Full-thickness incisions were made on the left colon and fibrin glue was applied over the sutures in experimental groups. The samples were taken on day 10.
Result: According to hydroxyproline levels (mcg/gr tissue), average values of the groups was 201.18 ± 27.81 (Group 1), 208.73 ± 17.81 (Group 2), 245.83 ± 20.47 (Group 3), and 241.55 ± 16.85 (Group 4). Tissue hydroxyproline levels in experimental groups were significantly higher compared to control (P < 0.05). In experimental group, mean hydroxyproline levels in subject with continuous suture was lower than simple interrupted suture; however it was not significant statistically (p=0.796).
Conclusion: As a result, the use of fibrin glue is beneficial to increase hydroxyproline level incolon anastomotic tissue especially in simple interrupted than continuous suture technique.
Keywords: fibrin glue, simple interrupted suture, continuous suture, colon anastomosis, peritonitis
Background often must be faced by a surgeon. This situation exposes a surgeon to a difficult choice, considering that make a Bowel resection in peritonitis caused by bowel anastomosis in peritonitis conditions has a higher gastrointestinal disease is one of the conditions that risk of leakage. The reported leakage rate of intestinal anastomoses is 1-19%, while the mortality rate can be Corresponding Author: as high as 13-27%.1,2,3 The rate of anastomotic leakage Agung Fuad Fathurochman; First Author; Dr. Soetomo General Hospital Surabaya; is also influenced by its anatomical location, more [email protected] distal the location has higher leakage rate. In ileocolic anastomosis the leakage rate is estimated to be 1-3%, 192 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
the left colon is 6-12% and about 3-19% in colorectal more water tight than simple interrupted sutures. anastomoses1,2. In the case of colon anastomosis On this basis, we conducted a study on experimental resection accompanied by peritonitis, the leakage rate animals to investigate the effect of fibrin glue on colon increases by 2.5 times.4 Complications that caused by anastomosis using simple interrupted sutures and the failure of the anastomotic wound healing process are continues sutures in intra-peritoneal infection conditions the causes of longer treatment time, decreased quality which are the high risk of leakage in rats experimentally of life, leading to increased mortality in patients.5 measuring hydroxyproline levels in intestinal Therefore some surgeons still consider peritonitis as a anastomotic tissue. contraindication for primary anastomosis and prefer 6,7 repeated surgical procedures . Method Bacterial infection, hypoxia and inflammation in This research had previously received approval the anastomotic area are conditions that can disturb the from the Ethics Committee of the Faculty of Veterinary 8 anastomotic wound healing process. The infectious Medicine, Airlangga University, Surabaya. A total of 40 process provokes an inflammatory response in the Wistar mice were divided into 4 treatment groups, there anastomotic area while the inflammatory phase could are control group (groups 1 and 2) and the treatment destroy collagen deposition, collagen is the main group (groups 3 and 4). All experimental animals were elements affecting wound healing and the strength of induced by peritonitis by using fecal suspension using anastomosis so that infection can disturb the normal 2 grams of feces from each rat, stirred into 20 ml of 9,10,11 healing process . Various parameters of collagen normal saline (NaCl 0.9%). This solution is then filtered metabolism are used to assess the wound healing process to remove large particles. This fluid suspension is then of intestinal anastomoses. One way is to measure the injected as much as 5 ml / kg into the intraperitoneal levels of tissue hydroxyproline. Hydroxyproline is an cavity by injection in the left iliac quadrant. Then the amino acid that is almost exclusively found in collagen mice will be observed to see signs of changes in behavior, tissue, so the measurement of hydroxyproline levels can body hair, and breathing frequency. be used to measure collagen metabolism and regulation.12 After 24 hours of induction of peritonitis in Currently, the main single layer suture with the experimental animals, a laparotomy and resection - simple knot technique is the gold standard which is often anastomosis will be performed. Anesthetized using 13 used in intestinal anastomosis. However, the simple Ketamine HCL 50 mg / kg by intramuscular injection. knot suture is not water tight, so that anastomotic wound Before the anastomosis procedure, the peritoneal fluid is at risk of contamination with infected peritoneal fluid, is taken for microbiological examination. In group 1 while the continues suture is more water tight so it is anastomosis was performed with simple knot suture, in 14,15 safer from contamination of the wound. The idea group 2 with continuous suture, group 3 with simple knot of providing a protective layer in the anastomotic area suture added with fibrin glue and in group 4 with baste to prevent leakage is a sensible alternative to action. suture plus fibrin glue. Anastomosis using polyglycolic Tissue adhesives, especially fibrin glue have been used acid (Safil®), round needle. All experimental operations in various fields of surgery for tissue fusing, adhesion, were performed by the same surgical operator blindly to hemostasis, and wound healing. Fibrin glue acts as a avoid bias. The rats that were included in this study had barrier to the wound area, where the fibrin glue make been fasting for 12 hours before surgery. After surgery, a sealant within ± 3 seconds, so bacteria cannot enter ceftriaxone antibiotic injection of 25 mg / kg was given 16 the anastomotic suture. The basic concept that fibrin by intramuscular injection every 12 hours. They were glue may be used to strengthen intestinal anastomoses is caged individually, fed standard pellets and water ad not new concept, but the results of existing studies have libitum. On the tenth day after the laparotomy, the rats shown no effectiveness and no consistent indications for were killed using high doses of Ketamine HCl injection 17 administration. In addition, it is a question whether for relaparotomy and tissue sampling. The anastomotic fibrin glue is useful in intestinal anastomosis with segment was cut along 5 mm proximal and 5 mm continues sutures, considering that continues sutures are distally. The specimen was then sent to the Genetics Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 193
Laboratory of the Institute of Tropical Disease to take a mixture of aerobic and anaerobic bacteria grew, with the tissue homogenate. Then the tissue homogenate was Escherichia Coli as the dominant bacteria. In this study, sent to the Clinical Pathology laboratory for examination in group 1, it was found that two rats died on the first of hydroxyproline levels using the ELISA method. The and third day after anastomosis. In group 2, two rats other mice that were not selected were then sacrificed died on the second and third day. In group 3, one rat without further examination died on the third day. Post-mortem examination revealed anastomotic leak. The dead mice were not further Result examined. Thus the number of rats examined further Twentyfour hours post inoculation with fecal amounted to 8 each per each treatment group. From rats induced peritonitis, all experimental animals were living on day 10, 8 rats were randomly taken from each looks like seriously ill, such as lethargy, standing group, except in groups 1 and 2 where only 8 survived. hairs on their bodies and decreased appetite. When A total of 32 rats were subjected to further examination. a laparotomy was performed, there were signs of The total number of experimental animals in this inflammation characterized by redness of the intestine study was 32 rats aged 10-12 weeks with weight of 250- due to increased vascularity and cloudy intraperitoneal 300 grams. The rats came from the same place of birth, fluid. This peritoneal fluid is then taken and examined were raised in the same place and were given the same microbiologically. In the microbiological examination food. Data for age and sample body weight are listed in of the peritoneal fluid of all samples, it was found that table 1 below.
Table 1. Average age, weight and duration of operation
Average simple Average simple Average Continous interrupted suture with Average Continous Parameter interrupted(1) Suture (2) fibrin glue (3) with fibrin glue (4)
age(week) 11 (±0.894) 10.83 (±0.753) 11 (±0.894) 10.67 (±0.816)
278.33 (±7.528) weight (gram) 275 (±16.432) 285 (±10.488) 276.67 (±10.328)
Duration(minute) 18.125 (±0.283) 17.50 (±0.926) 18.125(±1.36) 17.88 (±1.12)
Based on the data above using ANOVA test on the showed p = 0.621 (p> 0.05). This means that the length four sample groups showed that p> 0.05 (p = 0.434). This of operation in the four sample groups is not significantly means that the ages of the mice in the four sample groups different (in other words, it is equivalent). were not significantly different and were homogeneous. Hydroxyproline levels of anastomosis tissue between The average body weight of mice can be seen in table 1 groups above. Statistical test to compare the four sample groups using ANOVA showed that p> 0.05 (p = 0.434). This Ten days after treatment, intestinal anastomotic means that the body weight of mice in the four sample tissue specimens were taken to measure the groups is not significantly different and is homogeneous. hydroxyproline level. The samples that have been taken Based on the average length of operation of the sample are then converted into tissue homogenate preparations. group as seen on the table above, ANOVA test results Tissue homogenate was measured quantitatively by the 194 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
ELISA method to determine its hydroxyproline levels. Based on the results of measuring the hydroxyproline levels in each group, the mean hydroxyproline levels were analyzed in each treatment group with the results as listed in table 2 below.
Table 2 Average hydroxyproline measurement results (mcg/gr tissue)
Grup Average (mcg/gr tissue) Standard deviasion
Simple knot (I) 201.18 (±27.81)
Continous(II) 208.73 (±17.81)
Simple knot + fibrin glue (III) 245.83 (±20.47)
Continous + fibrin glue (IV) 241.55 (±16.85)
There was a significant difference in hydroxyprolin Administration of fibrin glue was shown to levels in the fibrin glue group compared to the group significantly increase the mean tissue hydroxyproline without fibrin glue. The research sample data was tested levels in group 3 compared to the control group (1), by the Shapiro-Wilk test because each group numbered (245.83 VS 201.18, p = 0.002). less than 50 samples. This test shows that the group c. Mean hydroxyproline levels in continous knot without fibrin glue distribution normally (group 1: p = vs simple knots 0.927, group 2: p = 0.195; p> 0.05) as well as the group using fibrin glue (group 3: p = 0.052, group 4: p = 0.263; In the control group, the mean hydroxyproline p> 0.05) Researchers used a parametric test to analyze content of baste> broken knots was statistically statistical comparisons between the four sample groups. insignificant (208.73 vs 201.18, p = 0.641). Meanwhile Parametric tests were chosen because all sample groups in the treatment group, the group of broken knots + fibrin were normally distributed. glue> baste + fibrin glue (245.83 vs 241.55, p = 0.796).
Post Hoc ANOVA test showed that the mean Discussion hydroxyproline levels in the treatment groups 3 and 4 In this study, we took samples of anastomotic (group of broken knots + fibrin glue and honest group tissue on the 10th day after surgery for several reasons, + fibrin glue) had a high mean difference (difference in including the fibrin glue that was applied which was mean) compared to other groups. Based on the data in expected to be completely absorbed so that it did not table 2 above, it is found: affect the results of measuring hydroxyproline levels20 a. Average hydroxyproline levels in the continuous besides that the formation of collagen in anastomotic knot suture tissue will peak on day 7, while fibrin glue that is applied over the anastomotic tissue will be fully absorbed on days Administration of fibrin glue was shown to 8-10 and its protective function is lost.18,19, 20 Collagen significantly increase the mean tissue hydroxyproline lysis due to collagenase activity contributes to low levels in group 4 compared to the control group (2); anastomosis strength, so that anastomoses are prone to (241.55 VS 208.73, p = 0.017. leaks and threads (loose sutures) in the first 10 days. This b. Average hydroxyprline levels in the simple collagenase activity occurs after injury in all intestinal knot suture segments, but is more pronounced in the colon than in the small intestine21,22. With sampling on the 10th day, it is hoped that the above process has been passed. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 195
From the results of this study, two important things the application of fibrin glue to wounds or anastomose were found, namely that the hydroxyproline levels can provide a protective effect on the anastomosis, between the control group and the fibrin glue group had seen from the hydroxyproline levels in the anastomosis significant differences and the hydroxyproline levels which were greater than the group without fibrin glue. between groups with different suture techniques had no These results indicate that the application of fibrin glue significant differences. This means that the application to anastomosis in a state of intraperitoneal infection of fibrin glue to anastomotic sutures has a major role provides a protective effect on the anastomosis so that in the production of collagen in colonic tissue in the the wound healing process can run well as in a state presence of intraperitoneal infection. From this it can without infection. This is thought to be due to several be seen that fibrin glue has a protective effect on the things, the first is that fibrin glue has functions such as wound healing process (anastomosis) in infectious hemostasis and supports the wound healing process. conditions, such as a study conducted by Senol in 2013. The second is due to the mechanical nature of the fibrin In Senol’s study, it appears that the amount of collagen glue which is sticky and watertight, this provides a in the peritonitis group with fibrin glue is the same as protective effect of anastomotic tissue from infection the amount of collagen in the group. control without around the tissue so that the wound healing process peritonitis. This shows that fibrin glue has the ability can run normally without the influence of infection and to protect against anastomoses and heal wounds.20 The surrounding inflammation.17 protection mechanism for fibrin glue is thought to be At the time of colonic anastomosis, PMN leucocytes due to several reasons, namely: it is sticky and water- first migrate into the wound during the inflammatory resistant so that it can provide a mechanical protective period. PMN also plays an important role in the sepsis effect on anastomotic tissue from surrounding infections, process25. The activation of systemic and intraperitoneal has a hemostasis function that supports the wound PMNs during intraperitoneal infection is caused by healing process, its nature is as a tissue adhesive which inflammatory mediators such as cytokines and reactive helps maintain the wound edge approximation.17,23 In oxygen species. When peritonitis occurs, cytokines addition, histologically, fibrin glue administration also (TNF-α, IL-1, IL-6, and others) are increased in the significantly increases neoangiogenesis and fibroblast systemic circulation and in the peritoneal exudate. activity. The adhesion rate is also higher in anastomosis These inflammatory cytokines will interfere with the accompanied by the application of fibrin glue19. healing process of intestinal anastomoses. Inflammatory In the healing process of intestinal anastomosis, reactions and chemo-attractants occur in anastomosis. collagen in the digestive tract is produced by fibroblasts Intraperitoneal PMN and circulating PMN collect in and smooth muscle cells. The amount of collagen affects perianastomotic tissue and increase the inflammatory the strength of the intestinal anastomosis. The amount reaction. When the inflammatory reaction increases, the of collagen peaks on day seven18. The initial strength of healing process is inhibited, so the amount of collagen the anastomosis depends on the ability of the existing will decrease.26 This can increase the risk of intestinal collagen tissue to hold the suture, while the newly formed anastomotic leakage. In the state of infection, there collagen fibers will restore the strength of the intestines to will be an increase in inflammatory mediator cells. In normal. So, collagen degradation and collagen synthesis anastomose tissue that is not protected by fibrin glue, after surgery are expected to influence the strength of there will be an increase in inflammatory mediator cells anastomosis. Collagen formation in anastomotic tissue including macrophages. Macrophages have several is disrupted in conditions of intraperitoneal infection, so effects, namely producing collagenase and inducing that anastomosis in the intestine is avoided24. apoptosis from fibroblasts. This condition decreases the amount of collagen and fibroblasts in the anastomotic Intraperitoneal infection is a condition that often area exposed to infected peritoneal fluid. Whereas the occurs in the state of intestinal perforation or leakage. anastomotic tissue with fibrin glue does not get exposure Intraperitoneal infection interferes with the wound so that no macrophages migrate to the anastomotic healing process by inhibiting fibroblast proliferation tissue.9 and collagen formation. In this study, it was found that 196 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Meanwhile, anastomotic suture technique colorectal surgery: a prospective monocentric does not have a major role in collagen production in study. Int J Colorectal Dis. 2018; 23: 265–70. healing colonic tissue in the presence of intraperitoneal 4. Bedeniuk A, Grytsenko Y, Grytsenko S, Horman infection. This result is in accordance with previous M, Boiko H. The Evaluation Of Risk Factors of studies which showed that suture technique in intestinal Anastomotic Leakage in Patients with Colorectal anastomosis does not play a role in wound healing, Cancer Complicated by Ileus. Int J Surg Med. 2017. seen from the number of fibroblasts in the anastomotic 5. Li YW, Lian P, Huang B, Zheng HT, Wang tissue.27 The baste technique has a higher average MH, Gu WL, Li XX, Xu Y, Cai SJ. Very Early hydroxyproline than the broken knot suture, but it is not Colorectal Anastomotic Leakage within 5 Post- statistically significant (p = 0.641). A study by Jiborn operative Days: a More Severe Subtype Needs reported increased vascularization in anastomotic tissue Relaparatomy. Sci Rep. 2017;7:39-6. with a single layer of anastomotic technique compared 6. Brasel KJ, Borgstrom DC, and Weigelt JA. to one-layer interruption. This is also supported by Management of penetrating colon trauma: a cost- research by Zografos which states that the increase in utility analysis. Surgery. 1999;125(5):471–9. vascularity is thought to be caused by an increase in the 7. Conrad JK, Ferry KM, Foreman ML, Gogel secretion of angiogenesis factors in the single layer baste BM, Fisher TL, and Livingston SA. Changing technique. This increase in vascularity will help in the management trends in penetrating colon trauma. fibroplasia phase, collagen synthesis and the formation Diseases of the Colon and Rectum. 2000; of extracellular matrix tissue.28,29 This condition may 43(4):466–71. also be caused by the nature of the baste suture which is 8. Snyder RJ, Lantis J, Kirsner RS, Shah V, Molyneaux more watertight than the broken knot suture so that it is M, Carter MJ. Macrophages: A review of their role safer against anastomotic wound contamination.14,15,30 in wound healing and their therapeutic use. Wound Repair Regen Off Publ Wound Heal Soc Eur Tissue Conclusion Repair Soc. 2016;24(4): 613–29. 9. Shi J, Wu J, Li Z, Ji J. Roles of Macrophage As a result, the use of fibrin glue is beneficial to Subtypes in Bowel Anastomotic Healing and increase hydroxyproline level in colon anastomotic Anastomotic Leakage. Journal of Immunology tissue especially in simple interrupted than continous Research. 2018. suture technique. 10. Ahrendt GM, et al. Intra-abdominal sepsis impairs Ethical Clearance: Taken from Ethical Committee colonic reparative collagen synthesis. Am J Surg. of Animal Research, Faculty of Veterinarian, Airlangga 1996; 171(1):102-8. University 11. Galanos, C., & Freudenberg, MA. Bacterial endotoxins: biological properties and mechanisms of Source of Funding:Self action. Mediators of inflammation. 1993;2(7):S11– 6. Conflict of Interest : Nil 12. Reddy GK & Enwemeka CS. A Simplified Method References for The Analysis of Hydroxyproline in Biological Tissue. Clin Biochem. 1996; 29(3): 225-9. 1. Kang CY, Halabi WJ, Chaudhry OO, et al. Risk factors for anastomotic leakage after anterior 13. Leslie, A., & Steele, R. J. C. The interrupted resection for rectal cancer. JAMA Surg. 2013; serosubmucosal anastomosis - still the gold 148:65-71. standard. Colorectal Disease. 2003;5(4):362–6. 2. Slieker JC, Daams F, Mulder IM, Jeckel J, Lange 14. Rassweiler JJ, Teber D, Frede T. Complications of JF. Systematic review of the technique of colorectal Laparoscopic Pyeloplasty. World J Urol. 2006; 26: anastomosis. JAMA Surg. 2013;148(2):190-201 539–47. 3. Buchs NC. Gervaz P. Secic M. Bucher P. Mugnier- 15. Ramalingam M, Murugesan A, Senthil K, Pai Konrad B. Morel P. Incidence, consequences, MG. A Comparison of Continuous and Interrupted and risk factors for anastomotic dehiscence after Suturing in Laparoscopic Pyeloplasty. JSLS. 2014; Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 197
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Ahmed Ebrahim Abdo1, Hesham Abd-Elhakam2, Ghada Abd-Elmonim3 1Maxillofacial Department, Faculty of Dentistry, Misr University For Science & Technology, Egypt. 2Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Cairo University, Egypt. 3Lecturer of Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Cairo University, Egypt.
Abstract Objective : To evaluate the neurosensory function of inferior alveolar nerve following the placement of an implant with Bypassing versus lateralization method. Methods : Twenty six partially edentulous patients were selected and equally grouped into 2 groups. In 1st group: implants placed by inferior alveolar nerve lateralization with Piezosurgery, while in 2nd group implants placed by computer guided surgical stent to bypass the inferior alveolar nerve. Then the neurosensory deficits are evaluated by subjectively and objectively tests. Assessment occurred at period intervals 2 ,8 & 24 weeks postoperatively. Results: there was statistically significant difference between the IANL & IANB especially at the early post-operative follow up, but with time there was no statistically significant difference. Conclusion: The inferior alveolar nerve lateralization technique has a higher initial rate of sensory dysfunction than the nerve bypassing technique with the aid of computer guided stent.
Key words: Dental implantation, Inferior alveolar nerve lateralization, nerve Bypass, Computer guided surgical stent, Trigeminal somatosensory evoked potential.
Introduction stability and allow the use of longer implants however, with neurosensory disturbance. (5-8) Many literatures have discussed the rehabilitation of the atrophic posterior mandibular area by different means. In the literature, Cutting of the cortical bone in the Some authors support the idea of use short implants but Inferior Alveolar Nerve Lateralization by Piezosurgery this choice can compromise the primary stability of devices with advantages such as selective cuttings, the implants. Other authors have succeeded in creating preserving soft-tissue structures and minimize thermal sufficient bone volume through ridge augmentation, but trauma.(9,10) Inferior alveolar nerve bypassing procedure several drawbacks, such as bone graft resorption & high is a modification in the path of implant placement to reduce (1- 4) morbidity at the donor site. Inferior alveolar nerve the risk of postoperative neurosensory dysfunction. lateralization (IANL) considered an alternative solution Planning to place the implant in either buccal or lingual to implant-based rehabilitation of severely mandibular directions with the aid of a surgical guide stent provided atrophied patients. With advantages such as primary that sufficient bone width is available between 5 - 6 mm, minimizes the risk of plate perforation. (11-14) Corresponding author: Ahmed Ebrahim Abdo Recently computer-guided implant placement E-mail: [email protected], procedure with stereolithographic templates has [email protected] become popular use. surgical planning was provided Mob. 01222936434 in both virtual and 3D environments, thus allowing the surgery to be performed virtually in an accurate Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 199
prosthesis-driven manner and exact transition of virtual to the mental foramen and extent at least 1cm beyond the planning by computer-aided surgical stent. (15-17) anticipated site of osteotomy was done. A mucoperiosteal Therefore, this current study was designed to assess fl ap was refl ected to expose the mandibular body and the neurosensory defi cits following implant placement by mental nerve. Blunt dissection was used to identify and inferior alveolar nerve bypass with aid of computed isolated the mental nerve. assisted surgical guide versus inferior alveolar nerve Osteotomy by Using a Piezosurgery device was lateralization (IANL) by using Piezosurgery device. performed. A posterior osteotomy should extend 2-3 cm Patients and Methods posterior to the mental foramen to avoid any loop of nerve and 1-2 cm posteriorly beyond the intended position of 2-1.Study design: the most distal implant for passive positioning of IAN. A randomized control trial conducted on 26 patients After carefully remove the posterior rectangular segment with edentulous posterior mandible. All the patients of the cortical bone overlying the nerve and identifying will be equally and randomly divided into two groups. the neurovascular bundle it retracted laterally (Fig.1) Placement of implants in atrophied posterior mandible cylindrical endosseous implants with Platelet Rich for patients in both groups was performed either by Fibrin (PRF) were placed medial to the inferior alveolar IAN lateralization using a Piezosurgery device (Group nerve using standard techniques. A) or IAN bypass using computer guided surgical stent (Group B).
2-2.Inclusion criteria
All patients were selected according to the following criteria:
Ø Atrophied posterior mandible provided with residual alveolar bone height of ≤ 8 mm above the inferior alveolar canal.
Ø No history for previous grafting procedures Fig.1 intra-operative photograph showing inferior or implant placement in the site planned for nerve alveolar nerve lateralization. lateralization. 2-3-2.For group B
Ø No systemic conditions could affect bone Construction of the surgical guide stent metabolism or predicted outcomes. Ø Image reconstruction by special software Cone beam computer tomography (CBCT) was (Ondemand 3D, Version 1.0.9. Cybermed, Korea) was performed Pre-operatively for all patient for assessment performed in axial, sagittal & coronal . Virtual implant of bone length and thickness, the position of the simulation with a suitable sized implant was selected mandibular canal in relation to the upper and lower such that the implant is 2 mm away from the inferior border of the mandible and planning for implant position alveolar canal surrounded by at least 1 mm of bone (for Group A) and to perform Virtual treatment plan bucco-lingually and at least 1.5 mm away from the with selection the suitable size and position for implant inferior border of the mandible. Care was taken to keep placement in all three dimensions and fabrication of axes compatible with the construction of the functional Surgical guided stent (for Group B). and stable prosthesis (fi .g 2)
2-3. Operative procedure
2-3-1. For group A:
Under local anesthesia, a mucosal incision superior 200 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Fig.2 showing the position of virtual implants form inferior alveolar canal. Fig.4 showing the fi xation of the surgical guide stent in patient’s mouth by fi xative pins. Ø The virtual implant and the bone images were fused together and saved as a new DICOM fi le. The Post-operative CBCT , instructions and medication new DICOM fi le containing the virtual implant planning were prescribed for al the patients. The prosthetic in bone was imported to another software (Innova 5, permanent loading of the installed implants was Anatomage, USA). An object in the form of a cylinder performed 6 months postoperatively. with diameter 2-3 mm was imported at the site of the 2-4. Neurosensory evaluation of the Inferior implant on the segmented cross – sectional view. Alveolar Nerve
Ø The surgical guide stent was designed with was performed 2, 8 & 24 weeks postoperatively metal sleeves for implant drills and insertion and fi xation through the following: screw to guaranty the fi xation of the guide in correct position during the surgery. (Fig.3&4) 2-4-1- Subjective tests
2-4-1-1.Patient Questioner (PQ): A score was given from 1 to 5 based on visual analogue scale.
2-4-1-2. Light Touch (LT): This performed with small piece of cotton wool with the patient’s eye closed; a stimulus was randomly applied to the test sites during 1 of 2 intervals which were 10 seconds apart.
2-4-1-3.Brush Directional Discrimination (BDD): The monofi lament was stroked across the skin in 1cm2 area, the response is considered positive if sensation is detected and in which direction the brush is moved, or negative if no sensation.
2-4-2- Objective test:
2-4-2-1.Trigeminal somatosensory evoked potential: it was achieved by Schnauzer-Myos unit.
Monopolar surface recording electrodes were fi xed to Fig.3 showing adjustment of the position of virtual scalp. The recording electrode was placed contra-lateral implants in axial, sagittal & coronal views & to the side of stimulation 2 cm posterior to C3 and C4 construction of surgical guide stent at the coronal suture (according to international 10- 20 system recording sites). A reference electrode was placed at mid frontal site and the array was earthed by a ground electrode placed behind the ear. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 201
Statistical Analysis Results Quantitative values were presented as mean Twenty six patients were included in the report, and standard deviation (SD). Data were explored for thirteen patients in each. In Group A the average range normality using Kolmogorov-Smirnov test of normality. of age was 53.46±4.943268, while in Group B the Independent t test was used to compare the 2 groups, average range of age was 56.66±3.452981. All cases while paired t test was used for intragroup comparison. proceeded with the complete healing except only one Qualitative values were presented as frequencies and case (7.69%) in (Group A) showed wound dehiscence. percentage (%) and were compared using chi-square 3-1 Subjective Neurosensory testing results: test. 3-1-1 Patients ‘own assessment questionnaire (PQ) results: (Table 1)
Table 1. Significance level p≤0.05, *significant, ns=non-significant
Group A Group B Group P value Period Mean Std Dev Mean Std Dev
2 W 1.54 0.78 3.62 0.96 <0.00001*
8 W 2.46 0.97 4.38 0.77 <0.00001*
24 W 4.54 0.52 4.85 0.38 0.09ns
NC = not computed (same mean and std dev)
Comparing means of previous observation periods two groups at 8 & 24weeks (p=0.062), (p=0.066) revealed that there was statistically significant difference respectively. between the 2 groups at 2 weeks and 8 weeks (p<0.0001), while at 24weeks, the difference was not statically 3-1-3 Brush Directional Discrimination (BDD) significant (p=0.09). Comparing the two groups regarding subjective 3-1-2 Light Touch (LT) test assessment (BDD) results revealed that:
Comparing the two groups regarding subjective Ø in group A : At 2 weeks, 100% of cases of assessment (LT) results revealed that: recorded “no”, At 8 weeks, 38.5% of cases of recorded “no”, At 24 weeks, 23% of cases recorded “no” Ø in group A : At 2 weeks, 100% of cases of recorded “no”, At 8 weeks, 38.5% of cases of recorded Ø in group B: 38.5% of cases recorded “no” At 8 “no”, At 24 weeks, 23% of cases recorded “no” weeks, 8% of cases recorded “no”. At 24 weeks, 0% of cases in recorded “no”. Ø in group B: 38.5% of cases recorded “no” At 8 weeks, 8% of cases recorded “no”. At 24 weeks, 0% of Chi square test revealed that there was statistically cases in recorded “no”. significant (p=0.0006) between two groups at 2weeks. While there was not statistically significant between Chi square test revealed that there was statistically two groups at 8 & 24weeks (p=0.062), (p=0.066) significant (p=0.0006) between two groups at 2weeks. respectively. While there was not statistically significant between 202 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
3-2 Trigeminal Somato-sensory evoked potential based on the conclusion of published studies by Rossini (TSEP) et al. (20), Maezawa et al. (21) ,Alex R. McDonald et al (22) who suggested the usage of magneto encephalography as N-Peak latency (ms) an objective monitor for evaluation of the post-traumatic Ø In group A: The mean difference of N peak inferior alveolar nerve injuries. latencies pre-operative to 2, 8 and 24 weeks post- Our results of subjective neurosensory function tests operative were 2.71±1.28, 0.98±0.54 and -1.01±0.49 revealed that there was statistical significant difference msec respectively. There was a statistically significant between two groups at 2 weeks postoperatively this difference in the first interval (pre-operative-2Weeks) was in the accordance with the observation of Hashemi (p=0.049), While there was no statistically significant et al, (5) who found 100% incidence of neurosensory change in mean N through the 2nd interval (Pre-operative disturbance on the first postoperative week after IANL. -8 Weeks) and 3rd interval (Pre-operative -24 Weeks) Our study relied upon the waveform latency and Ø In group B: The mean difference of N peak this is in agreement with other previous literatures (23, latencies pre-operative to 2, 8 and 24 weeks post- 24) that suggested waveform latency measurement to be operative were 0.19±0.13, -0.26±0.12 and -0.05±0.02 the most informative, reliable and diagnostic parameter msec respectively. There was no statistically significant of TSEP. The results indicate that the prolongation in change in mean N through all periods the latencies of first upward (N) and downward (P) Comparison of N-peak in both groups revealed a peak wave was the most marked features of sensory significantly higher mean was recorded in group A at 2 impairment postoperatively. This is consistent with the (25) and 8 weeks, (p=0.0044, p=0.0082 respectively). While study by Barkr et al., who found that latency delay at 24 weeks, there was no significant difference between between traumatized and control sides up to 2 or 3 msec. (26) both groups. could indicate for nerve injuries and Colella et al who showed that the preoperative latency period was Disscution significantly shorter than other postoperative periods in N and P peak latencies following bilateral sagittal split The use of piezoelectric device ( Group A) was osteotomy. based on the conclusions of the published studies (9,10) that considered the osteotomy with piezoelectric device In this study, the objective tests results were more is simpler and safer approach in Nerve Lateralization sensitive than the subjective tests. Our result goes in (IANL). agreement with previous studies (26,27) which found that the differences between objective and subjective IAN bypassing technique ( Group B) in accordance assessment may occur. with the previous studies (14-16) which considered the use of computer guided surgical stent for IAN Declaration bypassing technique can be optimized with reducing the possibilities of inferior alveolar nerve injury. Source of Funding: Self
For neurosensory nerve assessment we depend on Conflict of Interest: Nil Patients questionnaire, Light Touch (LT) and Brush Ethical Approval: Ethical approval and consent Directional Discrimination (BDD) tests as a subjective, to participate was taken from all the patients recruited preliminary evaluation tests for IAN function in in this study . This study was approved by Institutional accordance with Juodzbalys et al (18) and Antony et al Ethical Committee No -16/11/15 , data of signature (19), but because of low reproducibility and reliability 23/11/2016. of the previous tests as they depend on the patient’s subjective reporting of sensory information. Trigeminal References Somatosensory Evoked Potential used in our study as [1]. Esposito M, Buti J, Barausse C, Gasparro a quantitative measure for evaluation of IAN function R, Sammartino G, Felice P. Short implants Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 203
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1 2 3 Ahmed Mohammed , Mohammed Abujamal , Mariam Abdalla 1Ahmed Mohammed, MSc, BCPS, Work at Merit Health Centeral.1850 Chadwick Dr, Jackson, MS 39204. 2Mohammed Abujamal, MSc, BCPS, MBA, Lecturer, Pharmacy Practice Department, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard–Health Affairs, Riyadh, Kingdom of Saudi Arabia, 3Mariam Abdalla, MSc, BCPS, Lecturer, Pharmacy Practice Department, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard–Health Affairs, Riyadh, Kingdom of Saudi Arabia
Abstract Objectives: This review paper attempts to identify various factors that affect adherence to oral contraceptives (OCs)
Methods: We have searched related articles in the following data base through Google scholar advanced Google Scholar, the Cochrane Library, Pubmed, hinari, a Pop Line, Scopus, Science direct, the Cochrane register of Controlled Trials, and Medline. To identify factors affecting adherence to OCs and their association with contraceptive continuation.
Results: Many factors influence adherence to OCs. Factors that affect contraceptive failure rates and probabilities reported in the literature can be divided into three categories: Patient-related factors, factors related to health care providers and factors related to health care system.
Conclusion: More rigorous research is needed to understand factors affecting adherence to OCs continuation as well as, Counseling services should be expanded to address physical, social and emotional needs to improve continuation. Moreover, interventions to improve adherence and health system factors that prevent clients from using family planning consistently and effectively should also be addressed.
Key words: Factors, Oral contraceptives, Adherence and Compliance
Introduction since the medication must be taken on a long-term basis. Treatment regimens may be complicated, inconvenient, The degree to which patients act in accordance with and expensive, and it is not difficult to imagine why the advice or instructions of their health care provider adherence problems occur. (5) is termed adherence or compliance (1). These terms are commonly used interchangeably, even though the Oral contraceptive (OC) pills are the most popular former terminology may be preferred because of its hormonal method chosen by adolescents, and are more positive connotations (2). The term “compliance” extremely effective in preventing pregnancy (6). OCs has fallen into disfavor and has often been replaced with work primarily by suppressing ovulation with varying “adherence,” which more aptly describes medication- levels of estrogen and progestin. The effectiveness rates taking behavior from the patient’s perspective. One of vary based on the hormone levels in a particular pill the most often quoted definitions of adherence is “the and the woman’s physiologic make-up. With consistent extent to which a person’s behavior coincides with use on a regular daily routine the effectiveness rates medical or health advice (3). Compliance may be defined are 99.5–99.9% in avoiding pregnancy; with typical as an act of acquiescence (4). The issue of adherence to use OCs are 97% effective in preventing pregnancy, oral contraceptives (OCs) is in many ways similar to that yielding a failure rate of 0.5–3.0% (7-9). There is a high faced by clinicians attempting to treat chronic disorders, level of public awareness and acceptance of OCs, which 206 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
may increase a woman’s desire to use them, Women per cycle is three times more likely to become pregnant who choose OCs enjoy a high level of efficacy and than a woman who takes her pills consistently(7). It is the safety, ease of reversibility(1, 3), Other advantages are the health care provider role and responsibility to discuss all menstrual changes of less bleeding, fewer cramps, and of these advantages and disadvantages openly, clearly, fewer instances of hirsutism from androgen suppression. and at the patient’s level of understanding to give Acne is improved while using the combined OC pill complete disclosure of OCs (7, 10). that lowers testosterone levels. While some protection from pelvic inflammatory disease may be credited to the Materials and Method (2-6) pill. . It has been noted that there is a decrease in The methodology used in this paper consisted of the incidence of ovarian cysts secondary to decreased collecting peer-reviewed articles, publications and levels of luteinizing hormone and follicle-stimulating project reports, with focus on adherence and continuation hormone. Ectopic pregnancies also occur less frequently of contraceptive regimens, the search strategy involved in these users secondary to ovulatory suppression. the use of the following data bases: Google scholar Furthermore, studies have cited a decreased incidence advanced Google Scholar, the Cochrane Library, of endometrial and ovarian cancers with increased Pubmed, hinari, a Pop Line, Scopus, Science direct, the (4, 10) duration of OC use . The two major disadvantages Cochrane register of Controlled Trials, and Medline. historically associated with OCs use were the increased incidence of thrombophlebitis and pulmonary embolism Results and Discussion from hypercoagulability and cardiovascular disease Many factors influence adherence to OCs. Factors including hypertension. These were attributed to the that affect contraceptive failure rates and probabilities high estrogen levels in the earlier OCs. With the advent reported in the literature can be divided into three of combined oral contraceptives and lower hormonal categories: doses, these and other side effects have decreased significantly (5). Nausea, vomiting, abnormal menstrual 1. Patient-related factors. bleeding, headaches, enlarged breasts, weight gain, decreased libido, and mild depression have been cited 2. Factors related to health care providers as some trouble some side effects that could discourage 3. Factors related to health care system. a woman from using OCs. (7). It has also been shown that the majority of women who discontinue use of 1. Patient-related factors: OCs do so because of side effects such as weight gain, The majority of the studies employ patient irregular bleeding, and hair growth (6). Cessation of OCs perspective model. Of these, factors most commonly secondary to side effects and the subsequent nonuse of associated with non adherence with OCs are side effects another contraceptive method has accounted for 20% of such as breakthrough bleeding, spotting, nausea, heavy the annual unintended pregnancies in the United States periods, and amenorrhea. Women with these side effects (11). Other OCs disadvantages may include cost of the are significantly more likely to miss one or more pills medication, the need for frequent follow-up visits with each monthly cycle than women who do not. (6, 7). the health care provider, little partner involvement, and Many different issues affect patient adherence with oral a daily dosing regimen, in addiction It has been shown contraceptive method and they are important to consider that OCs demand strict adherence to the method to have in the total patient care picture. Table 1 identifies many maximum efficacy. more important thing is taking the pill of different issues that affect patient adherence to OCs. without missing ,when woman misses one or more pills Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 207
Table 1: Patient factors affecting adherence to OCs (8, 9-11)
Patient lifestyle, religious beliefs, socioeconomic status.
The personal desire to adhere.
Underlying medical problems that may affect the possibility of adherence.
Patient knowledge of a contraceptive method and its efficacy and how pregnancy occurs.
Level of patient error that can exacerbate nonadherence.
Contraceptive method side effects may be misdiagnosed as problems when they may be from nonadherence.
Patient’s personal reasons for adherence versus nonadherence.
The cost(s) of a specific contraceptive method and visits to the health care provider(s).
Partner support of and involvement with the patient’s choice(s) and use of contraceptive as prescribed.
2. Factors related to the health care providers: in discussion when visiting the physician, the attitude of the physician (friendly or antagonistic), the quality Health care providers should educate women to of communication and information provided by the critically evaluate which contraceptive method is best physician are all components of this interaction and are for her based on her cultural and religious beliefs, potential determinants of patient adherence. (21-23). background, individual desires and needs, and the probability of method adherence, address contraceptive Pharmacists have also essential role and can be method(s) side effects as a possible nonadherence issue. recruited to increase adherence by provide advice and Instruct the patient and individualize the information guidance to patients on how to manage their OCs. regarding the correct use of the contraceptive method. The role may include the use of educational tools and Evaluate the woman’s understanding of the material and the recognition of medication discrepancies (24, 25), her desire to use the method correctly, address any fears telephone counseling service, educational programmers about contraceptive method(s) that the patient may have. and follow-up visit(26), education plus icon labeled Use culturally sensitive materials, provide clear, relevant, medication containers plus therapeutic monitoring or and easy to understand written material regarding the the provision of collaborative care by pharmacists(22) proper use of a contraceptive method and what to do if the agree that pharmacists’ involvement was beneficial as method is used incorrectly; provide a telephone number they helped to augment adherence with medication. to call with other concerns and questions. Furthermore, Clinicians are the focal point for improving oral the providers should make sure patient has a follow- contraceptive adherence. They should focus counseling up appointment scheduled and that his/her office has on the transience of most side effects, instructions a method of reminding the patient of her upcoming on dealing with a missed pill, provision of a backup appointment, make sure the time, date, and place are method, and establishment of a daily pill-taking routine, convenient for the patient. Reinforce positive behaviors and easy-to-understand literature should be given to (e.g., using the method correctly and adhering to the patients to take home(21). There is enough evidence to (12-19) prescribed regimen . In addition there is another show that when clients are treated with care and respect approach hypothesizes that the interaction between and when their needs are met by service providers, they patient and provider is one of the primary determinants of will be more satisfied with the service; come back and (20) adherence. The degree to which a patient participates refer their family and friends to that clinic, research has 208 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
shown that good client–provider interaction is associated and having contraceptive samples. The third most with increased client knowledge and satisfaction with frequent response was to provide better follow-up care. services (26). Moreover, the medical literature shows A majority of these responses included suggestions that good client–provider interaction is associated with for improving communication between patient and increased adherence with medical regimens and with provider, spending more time with the patients and better better (25) health outcomes. One contributor to poor understanding to individual patient circumstances are communication between providers and patients about added very important value to increase adherence and contraceptive methods may be that providers have continuation to oral contraceptives. Other respondents incomplete knowledge of evidence-based information in public health center they can afford wrote materials about contraceptive methods. This is particularly that may help providers to improve their counseling relevant currently, as there has been a rapid expansion on particular topics such as how to use methods, side of contraceptive technology in the past decade (25) In effects, different method options available, and patient 2004, the World Health Organization released updated concerns and solutions. Improving access was the most eligibility criteria for contraceptive use and included frequently mentioned strategy, such topics as lowering recommendations for general practices and counseling, the cost of contraceptives for patients, providing better stating that “ counseling is a key element in quality insurance coverage for patients can be used in public of care and is also an important part of both initiation sector. Topics related to improving education, such and follow-up visits and should respond to clients’ as public service announcements, printed educational needs not only in contraception but also related to materials or manufacturer-provided inserts also are sexual transmitted diseases”. In addition to appropriate important to improve adherence. Beyond improving contraceptive counseling, other strategies for ensuring access and patient education, other individuals, such contraceptive success include removing barriers to use as partners, parents and pharmacists, should be more — such as waiting periods and prerequisite screenings involved in patients’ contraceptive care in public area. usually associated with provision of hormonal methods (22) Providers in health centers and clinics, especially private ones, report that insurance reimbursement is a 3. Factors related to the public health system: barrier to providing counseling, at least 46% of private providers and at least 21% of public providers reported From a public health perspective, continued and that changing insurance reimbursement to allow more consistent use of contraception would result in fewer time for counseling was very important. The fact that cases of unplanned and unwanted pregnancy and private providers are more likely than public providers lower incidence of unsafe abortion, a major cause of to report counseling reimbursement as a problem is maternal morbidity and mortality in many developing consistent with their being more dependent on insurance countries(27). In order to increase adherence, public health payments for the majority of their clients, Public sector system can establish Strategies for reducing patient and other committee, can successfully set guidelines costs by improving insurance (expanding coverage for for their own members and workers so as to lead them contraceptive care and expanding public insurance to in innovation and standard setting for the wider field include the uninsured) of contraceptive service providers. Private providers A related approach, changing insurance who provide contraceptive services, but are outside the reimbursement to allow for more counseling time, was scope of that group, could benefit by receiving more considered important, increasing initial counseling time information about newer protocols as well as some of the to help choose methods was essential , furthermore more standard tools for counseling and education used (28) public sector can Improve access to the services of oral by non-physician staff . In addition, more research is contraceptives and it consider the second most frequent needed on the impact of supplementing client–provider general response, The diverse responses in this category communication with other sources of patient information ranged from offering well trained staff, more office hours such as handouts and Internet websites. or walk-in service to providing low-cost contraceptives Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 209
Moreover, there are clearly structural differences system. between providers that are associated with what services Conflicts of Interest: The authors have no conflicts a patient receives. Private providers, who are typically of interest to declare. medical doctors, usually rely on their own clinical judgment about what services to offer a particular client, Funding information: No financial support for this based on her particular needs. However, because they are review that could have influenced its outcome. generally reimbursed only for specific medical services rendered during a visit, they may have incentives to Ethical Clearance: Our present article is a review tailor their care and to limit counseling services that are article. There is no need to get ethical clearance. generally inadequately reimbursed. On the other hand, clinicians at publicly funded clinics, who are typically References nurse practitioners or medical assistants, usually follow 1. Berg JS, Dischler J, Wagner D, Raia J, Palmer- a standard set of service delivery protocols that have Shevlin N. Medication compliance: a healthcare been developed by a medical director and are designed problem: Harvey Whitney Books Company; 1993. to provide the full range of available services to the 2. Sackett DL, Snow JC. The magnitude of compliance majority of clients. The existence of such protocols may and noncompliance. Compliance in health care. also contribute to prove that the clients receive the care 1979:11-22. prescribed, even if actual practice differs somewhat 3. Sethi W, CL F. Improving patient compliance. from the protocols (22) Optometry Today, August. 2012; 17:51-4. 4. Banning M. A review of interventions used to This review discussed-in these section- approaches improve adherence with medication in older. related to accessibility and financing of services and International Journal of Nursing Studies. 2009. to improvement the counseling practices and service 5. Haynes RB, Sackett DL. Compliance in health delivery protocols available to all women seeking care: Johns Hopkins University Press; 1979. contraceptive care. Additional research is needed to evaluate the effectiveness of specific practices and to 6. Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: risk indicators for assess the outcomes associated with the practices of poor pill taking and discontinuation. Contraception. different types of contraceptive service providers. 1995;51(5):283-8. Limitations of this study include the use of a 7. Killick S. Ovarian follicles during oral contraceptive convenience sample of providers at meetings of national cycles: their potential for ovulation. 8. Fertility and medical specialty organizations. This bias would likely Sterility. 1989;52(4):580-2. result in an underestimate of the number of subjects 9. Cramer JA. Compliance with contraceptives answering questions incorrectly, as providers at these and other treatments. Obstetrics & Gynecology. meetings and those willing to volunteer for research may 1996;88(3):4S-12S. be more informed about evidence-based practice than the 10. Parker RM, Williams MV, Baker DW, Nurss JR. general population of providers. Additionally, this study Literacy and contraception: exploring the link. focused on seven specific questions about contraceptive Obstetrics & Gynecology. 1996;88(3):72S-7S. care and did not address all relevant issues in this area. 11. Blackburn R, Cunkelman A, Zlidar VM. Oral Further research would help illuminate the topics most contraceptives--an update. Population reports important for integration into medical education. Series A: Oral contraceptives. 2000;28(1):1. 12. Hall KS, White KOC, Rickert VI, Reame N, Conclusion Westhoff C. Influence of depressed mood and Many factors influence adherence to OCs. Factors psychological stress symptoms on perceived oral that affect contraceptive failure rates and probabilities contraceptive side effects and discontinuation in reported in the literature can be divided into three young minority women. Contraception. 2012. categories: Patient-related factors, factors related to 13. Dehlendorf C, Levy K, Kelley A, Grumbach K, health care providers and factors related to health care Steinauer J. Women’s preferences for contraceptive 210 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
counseling and decision making. Contraception. 21. Williams A, Manias E, Walker R. Interventions 2012. to improve medication adherence in people with 14. Moreau C, Cleland K, Trussell J. Contraceptive multiple chronic conditions: a systematic review. discontinuation attributed to method dissatisfaction Journal of advanced nursing. 2008;63(2):132-43. in the United States. Contraception. 2007;76(4):267- 22. Wu JY, Leung WY, Chang S, Lee B, Zee B, 72. Tong PC, et al. Effectiveness of telephone 15. Lete I, Doval JL, Pérez-Campos E, Lertxundi R, counselling by a pharmacist in reducing mortality Correa M, de la Viuda E, et al. Self-described impact in patients receiving polypharmacy: randomised of noncompliance among users of a combined controlled trial. BMJ: British Medical Journal. hormonal contraceptive method. Contraception. 2006;333(7567):522. 2008;77(4):276-82. 23. Nazareth I, Burton A, Shulman S, Smith P, Haines 16. Dinerman LM, Wilson MD, Duggan AK, Joffe A, Timberall H. A pharmacy discharge plan for A. Outcomes of adolescents using levonorgestrel hospitalized elderly patients—a randomized implants vs oral contraceptives or other controlled trial. Age and Ageing. 2001;30(1):33- contraceptive methods. Archives of pediatrics & 40. adolescent medicine. 1995;149(9):967. 25. Lu CY, Ross-Degnan D, Soumerai SB, Pearson 17. Hulka BS, Cassel JC, Kupper LL, Burdette JA. S-A. Interventions designed to improve the quality Communication, compliance, and concordance and efficiency of medication use in managed care: between physicians and patients with prescribed A critical review of the literature–2001–2007. medications. American Journal of Public Health. BMC Health Services Research. 2008;8(1):75. 1976;66(9):847-53. 26. Rosenberg M, Waugh MS. Causes and consequences 18. King MC, Ryan J. Woman abuse: The role of of oral contraceptive noncompliance. American nurse-midwives in assessment. Journal of Nurse- journal of obstetrics and gynecology. 1999;180(2): Midwifery. 1996;41(6):436-41. S276-S9. 19. Garrity TF. Medical compliance and the clinician- 27. Rowlands S. New technologies in contraception. patient relationship: A review. Social Science BJOG: An International Journal of Obstetrics & & Medicine Part E: Medical Psychology. Gynaecology. 2009;116(2):230-9. 1981;15(3):215-22. 28. Smith R, Ashford L, Gribble J, Clifton D. Family 20. Neel EU, Litt IF, Jay MS. Side effects and planning saves lives: Population Reference Bureau compliance with low-and conventional-dose oral Washington DC; 2009. contraceptives among adolescents. Journal of Adolescent Health Care. 1987;8(4):327-9. DOI Number: 10.37506/ijphrd.v12i1.13851 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 211 Approaches Used to Improve Adherence to Oral Contraceptives
1 2 3 Ahmed Mohammed , Mariam Abdalla , Mohammed Abujamal 1Work at Merit Health Centeral.1850 Chadwick Dr, Jackson, MS 39204, 2 Lecturer, Pharmacy Practice Department, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard–Health Affairs, Riyadh, Kingdom of Saudi Arabia, 3Lecturer, Pharmacy Practice Department, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard–Health Affairs, Riyadh, Kingdom of Saudi Arabia
Abstract Objectives: The objective of this review the approaches for improving oral contraceptives (OCs) adherence.
Methods: The search strategy involved the use of the following data bases: Cochrane Library, Pubmed, hinari, a Pop Line, Scopus, Science direct, the Cochrane register of Controlled Trials. Types of study are original Research studies, RCTs, systematic reviews, full text articles.
Results: Adherence is a shared responsibility of patients, clinicians, and manufacturers; the patient and clinician are the focal points for these efforts. Counseling must be individualized, which requires knowledge of factors that predict adherence and understanding of the patient’s decision making process as it relates to medications.
Conclusion: Improving adherence and preventing early discontinuations is a shared responsibility of OCs users, health care providers, and OCs manufacturers. Manufacturers should recognize that the provision of written materials that are both informative and easy to understand can improve patient compliance. Continued improvements in OCs formulations are important in reducing unwanted side effects. However, our findings suggest that providers are the focal point for helping women to become more successful OCs users.
Key words: Oral contraceptives, Adherence, Discontinuations, Oral contraceptives and counseling
Introduction extent of non-adherent behavior-reported compliance rates vary from 19% to 100%(3, 4), In addition, the Adherence with medication is a complex and definition and measurement of adherence often vary intriguing behavioral issue which has been the focus from study to study, making generalizability difficult(3). of much debate. Multiple methods have been studied Definitions of compliance range from the percentage of to measure adherence, but no single measure can be tablets consumed in a defined time span to classifications considered the gold standard for all types of adherence such as errors of omission, dosage, timing, or purpose(5). research. In addition, multiple interventions are required to improve adherence with acute as well as chronic Medication regimen compliance is often described medication regimens. No simple, single adherence as having a single dimension when several distinct types (1, 2) intervention is useful by itself. Therefore, medication of noncompliant behavior exist: (a) the patient may fail regimen adherence continues to be a major problem, to take any medication, (b) the patient may discontinue because many reports of adherence lack precision, therapy prematurely, and (c) the patient may continue and interventions to improve adherence are difficult to to take the medication but deviate from the prescribed implement. Large disparities have been reported in the 212 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
regimen (6). These types of behavior should be clearly areas are appropriate for emphasis, and ensure that the delineated when referring to medication regimen patient understands information that serves as the basis adherence or compliance. For example, two separate for proper OC use (11) studies may report that medication regimen compliance A. Health care providers (4, 6, 10) was 50%. However, 50% compliance in the first study may indicate that one half of the patients stopped 1. Individually adjust contraceptive choice; help therapy, whereas in the second study it may indicate that each woman think through the choice according to patients consumed an average of 50% of the total doses background and individual needs and concerns. prescribed over a specified time (7). Non-adherence with medication is not a new issue. Often patients do 2. Stress importance of daily routine for pill taking. not disclose their medication taking behavior. Equally 3. Discuss the transient nature of most OC side prescribers may be unaware of their patients’ medication effects in new users, especially spotting and bleeding. taking practices. Non-adherence with medication can be classified as intentional, often related to the need to avoid 4. Dispel OC myths and misinformation; discuss drug-related adverse effects (8, 9), or unintentional related noncontraceptive health benefits of OCs. to cognitive or visionary impairment, poor cognition (10), or due to poor educational achievement or forgetfulness. 5. Demonstrate correct use of specific OC package Unlikely, few large studies of OCs adherence have prescribed. been conducted in the general population. The existing 6. Provide easy-to-understand instructions in both literature on contraceptive use focuses on adolescents, oral and written forms on proper use and dealing with and the large majority of these studies involve small missed pills. numbers of subjects that are not able to differentiate between a numbers of risk factors. The objectives of this 7. Suggest backup contraceptive method if she review are to, (A) Identify factors affecting adherence to missed one or more pill. OCs, (B) Identify impact of non-adherence to OCs, and 8. Provide means for patient to get additional the approaches for improving OCs adherence. information about OCs and their use if she has questions Materials and Method later. The search strategy involved the use of the following 9. Use follow-up contact to look for signs of data bases: Cochrane Library, Pubmed, hinari, a Pop noncompliance; for example, calls about spotting should Line, Scopus, Science direct, the Cochrane register of be a flag for inconsistent use and an opportunity to Controlled Trials. Types of study are original Research review instructions. studies, RCTs, systematic reviews, full text articles. In B. OCs users (11): total 60 reports were selected for in-depth evaluation and, of these 25 research studies emerged that examined 1. Establish a regular time to take OC, preferably as adherence with OCs. References and articles were part of daily routine such as brushing teeth. selected from a 10- year period from 2003 to 2013 as it was shown the most relevant studies pertinent to the 2. Carefully read literature that accompanies pill subject area would be located within this period and package. would reflect the currency of the available literature. 3. Know what to do if pills are missed. Results and Discussion Discussion Approaches used to improve adherence to OCs The choice of currently available contraceptive Several strategies to improve OCs use may prove methods has increased considerably in recent years, fruitful the clinician serves as the focal point for these, offering women of reproductive age a variety of because he/ she must assess each patient, decide which different methods depending on their needs and lifestyle. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 213
The contraceptive pill is the most widely used method use of a contraceptive method may affect the user’s of contraception , with 65% being pill users, which long-term experience and satisfaction with the method. is consistent with data of a comprehensive survey IN one study which concern about depressed mood, conducted among 12,138 randomly selected women from psychological stress and perceived weight changes were five countries (12). The efficacy of oral contraceptives, independent predictors of OCs discontinuation among however, depends on women consistent and proper young minority women in the study. Other researchers use. Women who use oral contraceptives inconsistently have reported on associations between perceived are almost three times more likely to experience an weight side effects, in particular, weight gain, and OCs unintended pregnancy compared with women who take misuse (20, 21, 22) . The findings offer further support that their oral contraceptives consistently (13). As in one study, perceptions of weight side effects remain a persistent it has been recognized that contraceptive effectiveness is barrier to contraceptive continuation. It is unclear not simply a matter of technology but is also a matter of from these data why women with depressed mood or the influence of psychological and many other factors to psychological stress are more likely to discontinue OCs. which more attention should be paid to minimize non- In this review some result found that existing theories adherence-related problems (14). In another study, side on psychiatric mechanisms related to pill misuse more effects and menstrual disturbances were also the most generally suggest that women with adverse psychological common reason for dissatisfaction leading women to conditions may lack insight into their psychological discontinue OCs. However, the overall dissatisfaction distress and its impact on daily functioning, including rate leading to OCs discontinuation was lower than for pill taking (3). They may have diminished perceptions all other medical methods of contraception. In a large of benefits and threats of a contraceptive treatment and prospective study, Rosenberg and Waugh (15) showed susceptibility to pregnancy(11) or limited capacities for that 28 out of 100 OCs users discontinued the method risk assessment, planning and social learning(23-27) in this within the first 6 months of use, with probabilities of study they conclude that all of these cognitive processes discontinuation dropping sharply after the first three could interfere with a woman’s contraceptive behavior months of use. Almost half of OCs users (46%) in that and ability to make health decisions but require further study stopped using their method because of side effects investigation in regards to OCs use and depression and or doctor recommendations, while 14% discontinued stress, also psychological conditions may contribute because they considered the method too hard to use, to or exacerbate perceptions of negative OCs related too expensive or were concerned with hormones symptoms. Adherence rates may be improved by (16). all reasons that are likely to be categorized as method-specific counseling about side effects that a user dissatisfaction. Concerning these results, there is believe might expect, and, perhaps more importantly, targeted that a broader understanding of women’s concerns and method selection informed by the patient’s level of experience using contraception could help health care tolerance for certain kinds of side effects. Counseling providers redesign counseling strategies to improve that integrates consideration of the “method–user– contraceptive continuation. Further research in particular interaction” (12) may be useful in matching patients is needed to explore the factors that might influence with the contraceptive method that best fits their current contraceptive dissatisfaction ultimately leading to needs and provides ongoing satisfaction. In this review, discontinuation. These factors include women’s social very few studies examining the effect of enhanced and demographic characteristics, shown to be associated counseling have shown such a benefit (28-33). A recent with contraceptive discontinuation for method related Cochrane review examining strategies to improve reasons in the United States (17, 18). Longitudinal studies adherence and acceptability of hormonal methods found should also explore the impact of women’s changing only 1 out of 6 trials showing an effect of counseling on life circumstances on the concurrent dynamics of contraceptive continuation (34). However, in this review contraceptive use (9). In some study in this review, the they also conclude that published trials are limited decision-making process in choosing a contraceptive both in scope and quality; therefore, more research method, including the role of the health care provider (19, involving well-designed interventions is needed to 20), should be better understood; the reasons for initiating understand the potential role of the clinician in reducing 214 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
method dissatisfaction and improving contraceptive Ethical Clearance: Our present article is a review continuation (35). The lack of knowledge about article. There is no need to get ethical clearance. contraception between some providers has the potential effect on ability to provide quality contraceptive care References to patients, which could have an impact on their ability 1. Branden PS. Contraceptive choice and patient to prevent unintended pregnancies. As an example, compliance: the health care provider’s challenge. 29% of providers who were unaware of the WHO Journal of Nurse-Midwifery. 1998;43(6):471-82. recommendation to administer emergency contraception 2. Rosenberg MJ, Burnhill MS, Waugh MS, Grimes up to 120 h after intercourse (36). The finding that gaps DA, Hillard PJ. Compliance and oral contraceptives: in knowledge about contraception suggests the need for a review. Contraception. 1995;52(3):137-41. expanded efforts at education targeting health providers, 3. Haynes RB, Wang E, da Mota Gomes M. A critical attention to continuing medical education (CME) with review of interventions to improve compliance emphasis on evidence-based resources, such as the with prescribed medications. Patient education and WHO recommendations (37), has the potential to improve counseling. 1987;10(2):155-66. knowledge. 4. Haynes RB, McKibbon KA, Kanani R. Systematic review of randomised trials of interventions to assist Conclusion patients to follow prescriptions for medications. Improving adherence and preventing early Lancet. 1996;348(9024):383. discontinuations is a shared responsibility of OCs 5. Greenberg RN. Overview of patient compliance users, health care providers, and OCs manufacturers. with medication dosing: a literature review. Clinical Manufacturers should recognize that the provision of therapeutics. 1984;6(5):592. written materials that are both informative and easy to 6. Rogers P, Bullman R. Prescription medicine understand can improve patient compliance. Continued compliance: a review of the baseline of improvements in OCs formulations are important in knowledge-A report of the national council on reducing unwanted side effects. However, our findings patient information and education. JOURNAL suggest that providers are the focal point for helping OF PHARMACOEPIDEMIOLOGY- women to become more successful OCs users. They BINGHAMTON-. 1995; 3:3-36. must assure adequate initial counseling for patients 7. Grymonpre RE, Didur CD, Montgomery PR, about the correct use of OCs. To improve adherence, Sitar DS. Pill count, self-report, and pharmacy the prescriber should help a woman establish a regular claims data to measure medication adherence routine for taking her OCs, assure that she properly in the elderly. The Annals of pharmacotherapy. 1998;32(7/8):749-54. understands use instructions (including missed pill instructions), and knows where to get information in 8. Wright E. Non-compliance—or how many aunts the future if problems or questions should arise. When has Matilda? The Lancet. 1993;342(8876):909-1 OCs use is initiated, providers should emphasize that 9. Farmer KC. Methods for measuring and monitoring side effects are expected, though most will be transient. medication regimen adherence in clinical trials Since the occurrence of side effects is associated with an and clinical practice. Clinical therapeutics. increased likelihood of unintended pregnancy, providers 1999;21(6):1074-90. also need to emphasize the need to continue to take 10. Hughes CM. Medication non-adherence in the OCs reliably even if side effects do occur. Improving elderly. Drugs & aging. 2004;21(12):793-811. adherence through these measures will reduce the 11. Fernando B, McKinstry B, Sheikh A. Reducing incidence of side effects and unintended pregnancy. medication-related adverse events in elderly patients. Reviews in Clinical Gerontology. Conflicts of Interest:The authors have no conflicts 2006;16(1):79. of interest to declare. 12. van Eijken M, Tsang S, Wensing M, de Smet PA, Grol RP. Interventions to improve medication Funding information: No financial support for this compliance in older patients living in the review that could have influenced its outcome. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 215
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Ali Abd El Wahed Kotb1, Hatem Wael Amer2, Heba Mahmoud Dahmoush3 1Assistant Lecturer of Oral and Maxillofacial Pathology, Faculty of Dentistry, Cairo University, Egypt,2 Lecturer of Oral and Maxillofacial Pathology, Faculty of Dentistry, Cairo University, Egypt, 3Professor of Oral and Maxillofacial Pathology, Faculty of Dentistry, Cairo University, Egypt
Abstract Background: Head and neck cancer represents one of the most common cancer types. Numerous risk factors are implicated in the development of HNSCC. In our study we aimed to investigate the changes that occur in the oral mucosa of cannabis smokers and compare them to cigarette smokers and non-smokers.
Methods: Three groups of subjects were included in our study (33 in each group); cannabis and cigarette smokers, cigarette smokers and non-smokers. The biopsies were examined by routine H&E techniques and immunohistochemical expression of p53.
Conclusion: The present work demonstrated evident dysplastic and pre-dysplastic changes in H&E stained sections. The changes were detected histologically in both smoker groups. These changes were more pronounced in cannabis smokers’ group than cigarette smokers’ group. Moreover, p53 immunostaining was higher for cigarette smokers’ group than cannabis smokers’ group. It is evident that cigarette smoking and cannabis smoking results in field changes in the oral mucosa which are detectable in tissue sections. These changes, such as hyperplasia and dysplasia are more detectable in H&E sections of cannabis smokers than cigarette smokers. However, positive p53 immunoexpression was lower in cannabis smokers than cigarette smokers.
Key words: Head and neck cancer, oral cancer, cannabis smoking, cigarette smoking, field cancerization.
Introduction in adjacent clinically normal tissues occur, which are prone to development of synchronous and metachronous Oral cancer is the 11th most common malignancy tumors. The field cancerization theory emphasizes high in the world 1 and is the most common type amongst probability of recurrences in head and neck squamous all head and neck cancers with an annual incidence of cell carcinoma patients 4. about half a million new cases and around 300,000 death each year (1%–2% of all cancer death) 2 .Among all oral Multiple factors have been involved in the etiology cancers, oral squamous cell carcinoma (OSCC) accounts of oral cancer. Simultaneous cigarette smoking and for 90% of them 3. alcohol consumption produce their synergistic effects and are by far the strongest factor in oral carcinogenesis Field cancerization is quite a new terminology in 5. Cannabis can be used by smoking (combined with the cancer field, it indicates that, when cancer develops tobacco), within food or as an extract. Cannabis in a tissue, group of genetically altered clones of cells smoking releases its main chemical component which is the tetrahydrocannabinol (THC) which is then absorbed 6 Corresponding author: into the bloodstream via the lungs . Ali Abd El Wahed Kotb Cannabis is listed as the most commonly used E-mail: [email protected] illegal drug in the world. Estimated on the basis of Cell phone: 002-01010937493 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 217
official statistics reported to the UN and WHO, there simultaneously exposed to any other carcinogenic are many countries that demonstrate increased number substance was done 10. of cannabis users. This list includes the United States, A) Selection of cigarette smokers: Canada, as well as Australia and New Zealand 7,8. Cigarette smokers included in the study were Worldwide cancer research has not been directed frequent smokers (at least 10 cigarettes a day) for a enough to look at the effect of cannabis on cancer. period not less than 5 years 10. Cannabis smoking related carcinogens have usually been mixed with tobacco smoking ones. It has been B) Selection of simultaneous cigarette and cannabis suggested that this combination increases the risk of head smokers: and neck cancer. However, others claim that cannabis kills cancer cells in vitro. In addition, numerous cell Simultaneous smokers in the study were frequent cultures showed antitumor effect in various cancer types cigarette smokers (at least 10 cigarettes a day) for a However, tumor destruction in the laboratory is much time period not less than 5 years plus frequent cannabis easier than in a live person and this has to go through the smoker (at least 3 times per week) for a period not less full process of animals and in-vivo testing to make sure than 5 years. They must fulfill both inclusion criteria. of its effect. The lack of profound safety, funding and Subjects were only involved if they were effective clinical trials make it very difficult to assess the undergoing simultaneous oral surgical procedures after potential benefits and risk of using cannabinoids in many filling an informed consent form stating that they agree cases. Smoking is the most common way of marijuana to participate in the study. Approval was obtained from use. However, this is medically unsuitable. Moreover, the ethical committee of the Faculty of Dentistry, Cairo the antitumor effects of cannabis have to overcome University before the beginning of the study. their known immunosuppressive effects which can be potentially pro-tumorigenic 9. An incisional biopsy was obtained from the buccal mucosa of subject (preferred due to rapid healing and All things considered, it is relatively evident minimal complications). The biopsies were an average that studies on the relationship between oral cancer size of 0.5 cm X 0.5 cm. The biopsies were fixed in and cannabis smoking independently lack the proper formalin and embedded in paraffin. From each block, depth due to the overlapping carcinogens for tobacco three cut sections were obtained at 4 μm thickness. One and tobacco/marijuana smoking or due to community was mounted on a glass slide and stained by routine restrictions. However, it is of utmost importance to hematoxylin and eosin (H&E) stain. Positively charged further investigate such a rapidly growing habit that slides were done for the other 2 sections for better might cause a burst in cancer related deaths within the adhesion during the immunohistochemical staining next few decades. procedure10 .
Materials and Methods Immunohistochemical staining was carried out 1) Selection of Subjects: using the automated immunostainer (AutostainerLink48, Dako, Denmark). Each section was stained using The specimens were obtained from three groups of the ready to use, monoclonal mouse antihuman P53 patients each group comprised 33 subjects: antibody (Clone DO-7, Code IR616, Dako, Denmark). 1- Nonsmokers. Examination of the stained sections was carried out using low and high-power light microscopy (Leica, 2- Cigarette smokers. Switzerland). Quantification of the cell count of the positive p53 immunoreaction was done using an image 3- Smokers of both cigarette and cannabis. analyzer computer system applying the software Leica All subjects had non-contributory medical history Quin 500 (Leica Microsystem, Switzerland). The and demonstrated no obvious oral lesions; exclusion most homogenous areas of reaction were evaluated to of subjects who had any systemic illnesses or were avoid edge artifacts. it was suggested that a positive 218 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 immunoexpression of p53 in 25% of the cells is a by cannabis smokers, with the lowest mean value was sufficient cut off value to indicate TP53 mutations11 . recorded in the non-smoking group. The difference between groups was statistically significant (p<0.0001) A standard measuring frame of 10 μm per ten according to one-way analysis of variance. Tukey’s post fields using a magnification x400 by light microscopy hoc test revealed a significant difference between each transferred to the monitor’s screen was used for automated two groups (tabel 2, fig 3). cell counting. Five fields were measured per section. It was suggested that a positive immunoexpression of p53 When considering how rapidly cannabis smoking in 25 % of the cells is a sufficient cut off value to indicate is a widely disseminated trend not only in our society TP53 mutations 11. but also worldwide, research should be directed towards this habit to try to uncover the relationship between Values were presented as mean and standard oral cancer and cannabis smoking and to solve the deviation (SD) values. Kolmogorov-Smirnov test was big question mark whether cannabis aggravates or used to check normality of the data which show that diminishes the harmful effects of cigarette smoking. most of the data were normally distributed (parametric data). Accordingly, one way analysis of variance In our study, hyperplasia was detected more in ANOVA test was used to compare between groups and cannabis smokers than cigarette smokers (78.7% for different intervals within the same group, followed by cannabis smokers versus 60.6% for cigarette smokers). Tukey’s post hoc test when the difference was found to This could be seen as a protective mechanism to the be significant. produced heat which is higher in cannabis smoking 12. Eventhough, basilar hyperplasia, nuclear hyperchromasia Results and Discussion and prominent nucleoli are closely related to the amount Histopathological Examination of Hematoxylin of DNA in the cells and is closely related to their and Eosin Stained Sections: rate of growth, division and protein synthesis. This could be seen as the earliest dysplastic features in the During microscopic examination of H&E spectrum of transformation of the normal oral mucosa stained sections dysplastic and pre-dysplastic features into a dysplastic one. However, these changes are not (hyperplasia) were detected in all smoking groups. exclusive to carcinogenesis, and may also be seen in Hyperplasia was found in a greater percentage in reactive epithelium 13 . cannabis smokers (78.7%) compared to cigarette smokers (60.6%). Pseudo-epitheliomatous hyperplasia was also The presence of frank dysplasia in some of the detected more in cannabis smokers (36.4%) compared subjects even though they presented normal mucosal to cigarette smokers (24.2%). Furthermore, increased appearance highlights the fact that histologic changes nuclear cytoplasmic ratio and prominent nucleoli were usually precede the clinical change and that dysplasia more pronounced in cannabis smokers. Moreover, in six could be present in oral mucosa with no clinical cases of cannabis smokers (18%) frank dysplasia was detectable changes and that large areas of cells are actually evident in the clinically normal oral mucosa affected by the carcinogenic insults that will be capable 4 compared to three cases of cigarette smokers (9%). later on to develop multiple primary tumors . Dyskeratosis was evident in 12.1% of cannabis smokers, The increase in the pre-dysplastic and dysplastic while it was found in 6% of cigarette smokers (tabel 1, features in all cannabis smoking subjects more than figs 1, 2). Subepithelial inflammation was also detected cigarette smoking subjects could be attributed to the in a few cases. higher heat produced by smoking cannabis in a hand Immunohistochemical expression of P53 rolled cigarettes or joints (the commonest way), the habit of smoking joints without filters to the smallest Positive nuclear p53 expression was mainly evident butt size till the proximal end, this is added to the manner in the basal cells and to a lesser extent in prickle cells. of cannabis smokers; they tend to hold their breath and The greatest mean number of p53 positive nuclei/high inhale deeply, all this leads to higher concentration of power field was observed in cigarette smokers, followed the smoke inhaled. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 219
The increased p53 positivity in cigarette smokers’ 17 interestingly concluded that the anticancer effect of group was an expected result. Cigarette smoking has CBD seems to be cancer selective in vitro. The efficacy been linked to many cancerous and precancerous of CBD has been linked to its diverse ability to target lesions specifically the oral and pharyngeal cancer with numerous cellular pathways that control tumorigenesis. a higher incidence of p53 mutations in smoking linked In 2018, Sultan et al.18 concluded that CBD inhibit cell carcinomas than the non-smoking linked carcinomas 14 . survival and induced apoptosis in a dose dependent manner through down regulating of cyclin D and p53 immunostaining relation with cigarette smoking inducing DNA fragmentation. Comparably, Jeong et was also confirmed by Mizobuchi, et al, 200011; they al., 2019 19concluded the same results on CBD induced examined p53 immunostaining in 74 patients with apoptosis by regulating many pro- and anti-apoptotic esophageaul squamous cell carcinoma. They concluded proteins, among which is Noxa, which normally that p53 was one of the main molecular targets of promotes activation of caspases and apoptosis. Noxa cigarette smoke in carcinogenesis. showed a significantly higher expression in human On the other hand, the lower p53 expression in colorectal cancer cell line subjected to CBD thus cannabis smokers could be linked to the anti-tumorigenic confirming its role as a novel, reliable anticancer drug. capability of cannabis that has been documented in the In line with our results, Zhang et al, in 2019 20 literature by Dariš et al, 2019 8. It has been also verified examined the in vitro effects of CBD on human gastric in a study by Śledziński et al, 2018 9. that cannabis cancer cells and concluded that p53 protein was highly could inhibit proliferation of cancer cells, and stimulate expressed and p21 protein was downregulated which their autophagy and apoptosis. Moreover, Hermanson subsequently inhibit the levels of CDK2 and cyclin E, & Marnett, 2011 15 concluded that cannabis can exert thus inducing cell cycle arrest at the G0–G1 phase. interesting effects on the cell line of many tumors, it can modulate cell proliferation, angiogenesis, reduce tumor The findings in the current work may support the growth, limit cellular migration and inducing apoptosis. claim that cannabis could play a context dependent role in cancer development. However, being mixed with Moreover, this lower expression in cannabis tobacco and being smoked is still problematic and may smokers’ group compared to cigarette smokers’ group mask the potential anticancer effect of cannabidiol on could be linked to the fact that the hand rolled cannabis malignant proliferating cells. Moreover, our observations joints are less densely packed compared to tobacco are not conclusive and should not be taken without cigarette which can lead to lesser load of carcinogens further investigation. p53 was the only marker used smoked in a breath. Also, this could be linked to the in this research and although positive cases confirm a CBD; another constituent of the cannabis sativa plant, field change effect, negative cases couldn’t be excluded which has been proven to be analgesic, sedating and anti- from having different forms of genetic mutations. A inflammatory16 and hence may play a role in decreasing panel of markers and genetic analysis should be done. the harmful side effects of THC; the major constituent of Social, educational and ethical background limited the the plant cannabis sativa. number of sample size and recruited cases. Moreover, The lower p53 immunoexpression in the cannabis it was extremely difficult to investigate the field effect smokers’ group may support the ideological concern of cannabis smoking without tobacco effect, this that being natural makes it harmless and better than overlapping of carcinogens requires higher stratification pharmacological synthetic drugs. In 2013 Massi, et al. and a bigger sample size. 220 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Figure 1:
Figure 1 (A&B): A. bar chart demonstrating the different levels of dysplastic and pre-dysplastic changes detected in the various groups. B. Column chart showing mean number of p53 positive nuclei/high power field in different groups. Figure 2:
Figure 2 (A&B): A. Photomicrograph of H&E stained section showing moderate epithelial dysplasia in a cannabis smoker (X200). B. Photomicrograph of H&E stained section showing epithelial hyperplasia in a cigarette smoker (X100). Figure 3:
Figure (3): Photomicrograph showing positive nuclear expression in basal cells of a cannabis smoker (X100) Table (1): The frequency of different dysplastic and pre-dysplastic changes assessed in the different groups. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 221
Cannabis smoker Cigarette smoker Non-smokers
Number of cases 33 33 33
Hyperplasia 26 (78.7%) 20 (60.6%) 12 (36.4%)
Peudo-epitheliomatous 12 (36.4%) 8 (24.2%) 1 (3%) Hyperplasia
Basilar Hyperplasia 12 (36.3%) 10 (30.3%) 3 (9%)
Dyskeratosis 4 (12.1%) 3 (9%) 0
Dysplasia 6 (18%) 3 (9%) 0
Table (2): Number of p53 positive nuclei/high power field in different groups and significance of the difference using ANOVA test: *significant at p<0.05
Control Cigarette smokers Cannabis smokers (Non-smokers)
Mean 1.33a 84.67b 73.22c
SD 0.37 11.79 11.89
Min 0 62 54
Max 3 97 99
F value 218.258
P value <0.0001*
Conclusions 4. p53 immunoexpression was highly significant 1. Cigarette smoking and cannabis smoking results between the control group and both cannabis smokers’ in field changes in the oral mucosa which are detectable group and cigarette smokers’ group. in tissue sections. 5. p53 immunoexpression was lower in cannabis 2. Hyperplasia and dysplasia are more detectable smokers than cigarette smokers which was statistically in H&E sections of cannabis smokers than cigarette significant at p<0.05. smokers. Acknowledgement: I would like to express my deep 3. Positive p53 immunoexpression was detected in gratitude to the residents of the oral and maxillofacial clinically normal oral mucosa of both cigarette smokers’ surgery department, faculty of dentistry, Cairo university group and cannabis smokers’ group indicating field for their efforts in collecting of the subjects and taking cancerization. the tissue specimens. 222 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
The authors declare that they have no conflict of 10- Amer HW, Waguih HM, El-rouby DH. interests Development of field cancerization in the clinically normal oral mucosa of shisha smokers. Int J Dent Source of Funding: There are no financial fundings Hyg. (2019);17(1):39-45. to disclose 11- Mizobuchi S, Furihata M, Sonobe H, et al. Ethical clearance: Taken from Research Ethics Association between p53 immunostaining and cigarette smoking in squamous cell carcinoma of the Committee, Faculty of Dentistry, Cairo University. esophagus. Jpn J Clin Oncol. (2000);30(10):423-8. References 12- Alawi F. Pigmented lesions of the oral cavity: an update. Dent Clin North Am. (2013);57(4):699- 1- Ghantous Y, Abu elnaaj I. GLOBAL INCIDENCE 710. AND RISK FACTORS OF ORAL CANCER. Harefuah. (2017);156(10):645-649. 13- Jalayer naderi N, Semyari H, Elahinia Z. The Impact of Smoking on Gingiva: a Histopathological Study. 2- Stenson KM, Brockstein BE, Ross ME. Iran J Pathol. (2015);10(3):214-20. Epidemiology and risk factors for head and neck cancer (2016). 14- Pfeifer, G. P., Denissenko, M. F., Olivier, M., Tretyakova, N., Hecht, S. S., & Hainaut, P.. 3- Vigneswaran N, Williams MD. Epidemiologic Tobacco smoke carcinogens, DNA damage and trends in head and neck cancer and aids in p53 mutations in smokingassociated cancers. diagnosis. Oral Maxillofac Surg Clin North Am. Oncogene, (2002);21(48), 7435. (2014);26(2):123-41 15- Hermanson DJ, Marnett LJ. Cannabinoids, 4- Mohan, M., & Jagannathan, N. (2014). Oral endocannabinoids, and cancer. Cancer Metastasis field cancerization: an update on current Rev. (2011);30(3-4):599-612. concepts. Oncology reviews, 8(1). 16- Schier AR, Ribeiro NP, Silva AC, et al. Cannabidiol, 5- Castellsagué X, Quintana MJ, Martínez MC, et al. a Cannabis sativa constituent, as an anxiolytic drug. The role of type of tobacco and type of alcoholic Braz J Psychiatry. (2012);34 Suppl 1:S104-10. beverage in oral carcinogenesis. Int J Cancer. (2004);108(5):741-9. 17- Massi P, Solinas M, Cinquina V, Parolaro D. Cannabidiol as potential anticancer drug. Br J Clin 6- Sharma P, Murthy P, Bharath MM. Chemistry, Pharmacol. (2013);75(2):303-12. metabolism, and toxicology of cannabis: clinical implications. Iran J Psychiatry. (2012);7(4):149- 18- Sultan AS, Marie MA, Sheweita SA. Novel 56. mechanism of cannabidiol-induced apoptosis in breast cancer cell lines. Breast. (2018);41:34-41. 7- United Nations Office on Drugs and Crime. (2018). World Drug Report 2018 (Sales No. E. 18. XI. 9). 19- Jeong S, Yun HK, Jeong YA, et al. Cannabidiol- induced apoptosis is mediated by activation of 8- Dariš B, Tancer verboten M, Knez Ž, Ferk P. Noxa in human colorectal cancer cells. Cancer Lett. Cannabinoids in cancer treatment: Therapeutic (2019); 447:12-23. potential and legislation. Bosn J Basic Med Sci. (2019);19(1):14-23. 20- Zhang X, Qin Y, Pan Z, et al. Cannabidiol Induces Cell Cycle Arrest and Cell Apoptosis in Human 9- Śledziński P, Zeyland J, Słomski R, Nowak A. The Gastric Cancer SGC-7901 Cells. Biomolecules. current state and future perspectives of cannabinoids (2019);9(8). in cancer biology. Cancer Med. (2018);7(3):765- 775. DOI Number: 10.37506/ijphrd.v12i1.13853 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 223 Platelet To Lymphocyte Ratio Relationship With Neoadjuvant Chemotherapy Of Caf Regiment Response In Locally Advanced Breast Cancer Patients
Ali Sibra Mulluzi1; Hantoro Ishardyanto2; Iskandar Ali2; Hartono Kahar3 1Resident of Surgery, Faculty of Medicine Universitas Airlangga /Dr. Soetomo General Hospital Surabaya, 2Staff of the Department of Surgery, Oncology Division, Faculty of Medicine Universitas Airlangga /Dr. Soetomo General Hospital Surabaya, 3Staff of the Department of Clinical Pathology, Faculty of Medicine Universitas Airlangga /Dr. Soetomo General Hospital Surabaya
Abstract Background: Chemotherapy in breast cancer can be given as neoadjuvant or adjuvant therapy. The response to neoadjuvant chemotherapy is very important in cancer management, especially in locally advanced breast cancer, therefore predictive factors which can predict chemotherapy response are very important. Platelet to lymphocyte ratio is a simple examination, which has been used as predictive factor in various cancer. This study will be focussing on locally advanced breast cancer.
Method: The study design is prospective cohort study. The research subjects examined the levels of platelets and lymphocytes in the blood before chemotherapy. Blood was drawn 1 day before the first chemotherapy session. Then the patient’s clinical response was assessed after 3 cycles of chemotherapy. Each cycle is carried out at intervals of 3 weeks. Furthermore, the platelet to lymphocyte ratio and chemotherapy response will be assessed and analyzed.
Results: The research subjects consisted of 35 women. In this study, it was found that the mean value of platelets was 388,228 ± 141.5 g / dl, with a maximum value of 834,000 g / dl and a minimum of 206,000 g / dl. In the lymphocyte, the mean results were 2,025 ± 759 mg / l with a maximum lymphocyte value of 4,210 g / dl and a minimum of 800 g / dl. From the results of this study, the mean platelet / lymphocyte ratio was 232.9 ± 212.9 uL with a minimum value of 80.51 uL and a maximum of 1052 uL. In this study, it was found that most of the patients experienced a partial response in 23 patients (65.7%) and it was found that there was a significant relationship between the platelet / lymphocyte ratio and the clinical response of local advanced breast cancer patients with p value = 0.028 (p. <0.05)
Conclusion: There is significant relationship between the platelet / lymphocyte ratio and the clinical response of chemotherapy in locally advanced breast cancer patients. The higher the platelet to lymphocyte ratio, worse chemotherapy response is expected.
Keywords: locally advanced breast cancer, platelet to lymphocyte ratio, chemotherapy, neoadjuvant
Background studies that discuss several predictive factors that are used, including: mitotic index and tumor differentiation Chemotherapy in breast cancer can be given and pleomorphism. Tumors can be differentiated good, in neoadjuvant or adjuvant ways. The response to moderate, and bad (grade 1, 2, or 3).1 Grade 3 tumors neoadjuvant chemotherapy is very important in cancer have a 4.4 times higher relative risk of recurrence management, especially in locally advanced breast compared with grade 1. Lymphovascular invasion of cancer, so predictive factors to predict chemotherapy several studies reported a risk of recurrence of 38% response are very important to know. There are many when present compared with 22% in cases where LVI 224 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
was absent. Histopathologic types, tubular, mucinous, people know its role. So it is hoped that by knowing the tubulolobular, and cribriform breast tumors have the PLR value, clinical later can make the basis of education best prognosis. These tumors have an overall survival to LABC patients about prognosis and prediction or Overall Survival (OS) of 10 years in 80% of cases. of chemotherapy response. PLR in peripheral blood Ductal, lobular solid, and mixed-type (ductal and lobular) before surgery was reported to represent an independent tumors have 10-year OS in only 50% of cases. The worst predictive factor in breast cancer 3. prognosis occurs with inflammatory carcinoma, which According to a study by Asano and colleagues, the has a 10-year OS in 30% of cases. A study of breast cancer platelet / lymphocyte or platelet to lymphocyte ratio subtypes found that patients with positive hormone (PLR) was reported as a predictive and prognostic receptors had a higher percentage of 5-year DFS and biomarker in the breast cancer group of patients, high OS. Her2 / neu expression can be used as a predictive PLR increased the risk of negative clinical response factor for a patient’s response to chemotherapy. Tumors threefold in the neoadjuvant setting. However, according with Her2 neu expression respond well and have a better to a 2018 Cuello-López study, PLR was not associated survival rate than Her2 neu negative tumors, when with the clinical picture of breast cancer patients treated with anthracycline-based chemotherapy. The rate receiving neoadjuvant therapy. From these controversial of tumor proliferation can be measured by KI-67, mitotic results, the authors are interested in conducting a study index, and S-phase fraction, Neutrophil Lymphocyte on the relationship between the platelet / lymphocyte Ratio (NLR) and Platelet Platelet Ratio (PLR) 2. ratio values at RSUD Dr. Soetomo Surabaya to assess Immunohistochemical examination (IHC) is needed in the the therapeutic response of local advanced breast cancer treatment of breast cancer to determine the submolecular patients receiving neoadjuvant CAF chemotherapy. type of cancer. Based on these molecular subtypes, prognostic and predictive of breast cancer therapy can Method be determined. Based on CPI examination, there are four types of breast cancer, namely luminal types (luminal A Research in the form of observational analytic and B), HER2-enriched types, and triple negative / basal research with prospective cohort design. Female patients like. Luminal types will respond to hormonal therapy, with locally advanced breast cancer who met the study while other types will respond with chemotherapy if inclusion and exclusion criteria were given an explanation needed. However, currently in Indonesia there are only 17 of the purpose and benefits of the examination, and hospitals that can carry out IHC examinations. Hospital were asked for consent to participate in the study by Type B does not yet have CPI examination facilities, signing the informed consent and the informed consent. so to complete the examination it is necessary to carry Furthermore, general data of the subjects such as out further examinations at the referral hospital. Due to name, age, gender, address and telephone number are limitations, there are some patients who discontinue IHC recorded. Other data is recorded according to the data examinations and continue to receive anthracycline- collection form. The research subjects examined the based chemotherapy. levels of platelets and lymphocytes in the blood before chemotherapy and every chemotherapy session. Blood Currently there are several simple and easy to was drawn 1 day before the chemotherapy session do biomarkers that can be predictors of neoadjuvant 1. Then the patient’s clinical response was assessed chemotherapy (NAC) response, one of which is the after 3 cycles of chemotherapy. Each cycle is carried platelet lymphocyte ratio (PLR). PLR is one of the out at intervals of 3 weeks. Furthermore, the platelet / hematological parameters that can be used to determine lymphocyte ratio will be assessed and its relationship the NAC response in patients with breast cancer. PLR with the clinical response of local advanced breast cancer can be used as an indicator to evaluate the systemic patients receiving CAF neoadjuvant chemotherapy. inflammatory response in cancer patients. Based on the results of research by Asano et al., 2016 (cut off point Results PLR 150), it was found that low PLR had a positive The study subjects consisted of 35 women (100%), response to NAC in LABC patients. PLR is a marker with the largest age being 35 - 50 years, namely 19 that is easy, cheap and fast to calculate, but not many Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 225 patients (54.3%) with a mean age of 47.94 ± 10.5. In this study, it was found that the most subtype of breast cancer was luminal A as many as 11 patients (31.4%) followed by Luminal B-like (positive HER-2) as many as 7 patients (20%) with the most type of anatomical pathology was ductal carcinoma, namely 25 patients ( 71.4%). Characteristics of research subjects can be seen in Table 1.
Table 1. Characteristics of Research Subject
Subject’s Characteristics Response (+) Response (-) Total Mean P value
< 35 years old 3 0 3
10.7% 0.0% 8.6%
16 3 19 Age 35 - 50 years old 57.1% 42.9% 54.3% 47.94 ± 10.5 0.386
9 4 13 > 50 years old 32.1% 57.1% 37.1%
18 7 25 Ductal Carcinoma 64.3% 100.0% 71.4% Histopathology 10 0 10 0.61 Non-Ductal Carcinoma 35.7% 0.0% 28.6%
5 6 11 Luminal A 17.9% 85.7% 31.4%
7 0 7 Luminal B-like (HER-2 positive) 25.0% 0.0% 20.0%
6 0 6 Molecular Luminal B-like
Subtype (HER-2 negative) 21.4% 0.0% 17.1% 0.013 5 1 6 Basal like 17.9% 14.3% 17.1%
5 0 5 Erb-B2 overexpression 17.9% 0.0% 14.3%
From the results of data analysis between the was also a significant difference between groups with characteristics between the patient’s age and the chemotherapy response (95% CI; p = 0.013). This can chemotherapy response, there was no significant be a confounding factor in this study. difference (95% CI; p = 0.386). From the analysis of the breast cancer pathology group, there was no In this study, it was found that out of 35 patients, significant difference between groups in chemotherapy the mean value of platelets was 388,228 ± 141.5 g / dl, response (95% CI; p = 0.61). Meanwhile, from the with a maximum value of 834,000 g / dl and a minimum analysis of the cancer pathology subtype group, there of 206,000 g / dl. In the lymphocyte results, the mean 226 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 results were 2,025 ± 759 mg / l with a maximum lymphocyte value of 4,210 g / dl and a minimum of 800 g / dl. From the results of this study, the mean platelet / lymphocyte ratio was 232.9 ± 212.9 uL with a minimum value of 80.51 uL and a maximum of 1052 uL. The thrombocyte / lymphocyte ratio in research subjects is shown in Table 2.
Table 2. Platelet to Lymphocyte ratio in Research Subjects
N Minimum Maximum Mean Std. Deviation
Statistic Statistic Statistic Statistic Statistic
Trombosit 35 206. 000 834. 000 388.228 141.583
Limfosit 35 800 4.210 2.025 759
Ratio 35 80.51 1052 232.9 212.9
Platelet to lymphocyte ratio value: The platelet to lymphocyte ratio value is the platelet type count divided by the lymphocyte type count. The results of the examination of platelets were compared to lymphocytes in the blood in uL units. The values will be divided into two categories, namely low with a value of <150 uL and high with a value of> 150 uL. In this study, it was found that most of the LABC breast cancer patients had a low platelet / lymphocyte ratio, namely 18 patients (51.4%). PLR categories of research subjects are seen in Table 3.
Table 3. Platelet to Lymphocyte ratio categories in Research Subjects
Category n Percentage (%)
High 17 48.6
Low 18 51.4
Total 35 100.0
The clinical response to chemotherapy is an evaluation of the change in tumor size as measured objectively through physical examination, divided into four categories, namely: progressive disease, stable disease, partial response, and complete response. In this study, it was found that most of the patients experienced a partial response, as many as 23 patients (65.7%). The clinical response is shown in Table 4.
Table 4. Clinical response in Research Subjects
Response n Percentage (%)
Complete Response 5 14.3
Partial Response 23 65.7
Stable Disease 7 20.0
Progressive disease 0 0
Total 36 100.0
Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 227
In this study, a relationship test of the independent and dependent variables in the form of ordinal and nominal data was carried out. From the research data obtained that the majority of patients who had a (+) response had a low platelet / lymphocyte ratio.
Table 5. Cross table of PLR and Chemotherapy response
Chemotherapy Response
Total Positive Negative p RR Response Response
17 1 18 Low 60.7% 14.3% 51.4% PLR Category 11 6 17 0,028 9,2 High 39.3% 85.7% 48.6%
Total 28 7 35
The relationship between the thrombocyte advanced breast cancer patients with a p value = 0.028 / lymphocyte ratio and the clinical response of (p <0.05), which means that there was a significant chemotherapy in locally advanced breast cancer relationship between the platelet / lymphocyte ratio. patients was tested using a chi-square test, it was found with the CAF chemotherapy response with a relative that there was a significant relationship between the risk was 9.2. The results of this study are in line with platelet / lymphocyte ratio and the clinical response of previous studies in assessing the predictive value of local advanced breast cancer patients with a p value = platelet counts and the ratio to other immune cells - 0.028 (p <0.05), which means that there is a significant including lymphocytes and neutrophils - in the context relationship between the platelet / lymphocyte ratio and of breast cancer. Breast cancer patients with a low the clinical response to CAF chemotherapy. In this study, platelet-to-lymphocyte ratio (PLR <150) who were it was found that the relative risk was 9.2, meaning that treated with neoadjuvant chemotherapy achieved a someone who has a low platelet / lymphocyte ratio has higher complete pathological response, regardless of a 9.2x higher chance of having a good chemotherapy tumor molecular subtype. Susceptibility to change under response than those who have a high platelet / lymphocyte various conditions. Increased numbers of neutrophils ratio as shown in Table 5. and platelets are often caused by inflammatory diseases, such as connective tissue disorders, drug administration, Discussion bacterial disease, or viral infections. The most common In this study, it was found that most of the LABC cause of a low lymphocyte count is recent infection. breast cancer patients had a low platelet / lymphocyte In addition, lymphocytopenia can also be caused by ratio (51.4%). and it was found that most of the patients infection, malnutrition, connective tissue disorders, experienced a partial response (65.7%). The relationship heavy stress, intense physical exercise, and medical 4 between the platelet / lymphocyte ratio showed that treatment . there was a significant relationship between the platelet Research conducted by Kim et al. In 2019, / lymphocyte ratio and the clinical response of locally in this study, HER-2-positive and TNBC tumors 228 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 showed the highest correlation between low PLR in a group of breast cancer patients threefold negative and rates of complete pathological response and in the neoadjuvant setting, since patients with low prognosis. The study included a large number of PLR showed higher levels of pCR, DFS, and OS. In a HR-positive breast cancers in the survival analysis. smaller cohort of breast cancer patients where a high PLR was significantly effective in determining the PLR was independently associated with poor response predictive value of breast cancer. However, in that to neoadjuvant chemotherapy. Results of the same study, a combination of NLR and PLR was suggested studies6,7 showed that PLR was associated with pCR, as a model for the CAF response with a potential role as being that patients with low PLR (<150) achieved higher a screening tool. Furthermore, the combination of NLR pCR rates (35.1% vs 22.2%, p = 0.03). Overall, these and PLR showed a significant predictive role in breast data support the role of PLR as a predictive variable cancer patients receiving neoadjuvant chemotherapy for pCR independent of tumor molecular subtypes. It is 5. For patients with breast cancer being treated with known that tumors with greater neoantigen synthesis - neoadjuvant chemotherapy, low PLR indicates high such as TN and Her2 - positive - can achieve a higher chemotherapy sensitivity, suggesting that PLR can anti-tumor immune response by increasing the number function as a predictive marker of the therapeutic effect of peripheral lymphocytes, and thereby potentiating of neoadjuvant chemotherapy 3. the effect of neoadjuvant chemotherapy. This is supported by studies that suggest tumor infiltration Research by Asano et al. In the Japanese population, lymphocyte (TIL) as a predictive biomarker of CPR in an association was found between low PLR ratio (cut- the neoadjuvant setting, especially in the early stages off: PLR <150), age (> 56 years) and postmenopausal of Her2-positive and TN tumors. In addition, TIL status (p = <0.001). Krenn-Pilko in 2014, showed that is of predictive value, because high TIL counts are a high PLR (cut-off: PLR> 292) was correlated with associated with improved overall survival, strongly high lymph node involvement and high tumor rates (p supporting the idea that immune system activation is = <0.05), while it was found that no correlation was essential for survival outcomes. In this study, there were found related to other clinicopathological variables. On patients who had a platelet level of more than 800,000 the other hand, research by Koh et al. 2015 reported based on data tracing, that the patient was currently in an association of height PLR (cut-off: PLR> 215) a respiratory tract infection condition. Based on the with age (> 50 years, p = <0.01) and tumor size (> 5 literature, patients with breast cancer are susceptible to cm, p = <0.01), while no association were found with infection due to decreased immune conditions. Based lymph node involvement or tumor grade (p = 0.091 and on the literature the causes of thrombocytosis include p = 0.06, respectively). In this study, PLR of patients thrombocytosis is a clinical condition in which a receiving neoadjuvant therapy was not associated with platelet count exceeds 2 standard deviation (SD) above clinical features including age (p = 0.611), menopausal the average. Some literature mentions thrombocytosis status (p = 0.209), tumor rade (p = 0.229), tumor size (p with a number that varies between 400 - 1000 x 103 / = 0.622), lymph node involvement. clear (p = 0.680), L. An excessive number of platelets can be caused by and stage (p = 0.570) 4. Tumor cells have been shown many factors, but can be grouped into three conditions, to induce the synthesis of platelet-stimulating factors namely: increased production caused by stimulation that support growth, invasion and metastasis of primary (reactive thrombocytosis), primary disorders such as tumors by several mechanisms. Thus, the blood platelet myeloproliferative or dysplasia syndrome (essential), count device could be an indirect indicator of tumor thrombocytosis associated with hematological diseases activity. On the other hand, detection of high peripheral such as chronic leukemia and polycythemia, reactive blood lymphocyte counts with antitumor activity - thrombocytosis is a secondary response to several particularly CD8 + T cells would be an indicator of conditions such as trauma, infection, inflammation, tumor suppression activity. Thus these data suggest and immune disorders. Predisposing factors for that patients with low PLR will have higher antitumor reactive thrombocytosis are acute or chronic infections, activity, a better prognosis, and a better chemotherapy hypoxemia, surgery, trauma, malignancy, bleeding, response. In a study by Asano and colleagues, PLR stress and splenectomy which generally occur due to the was reported as a predictive and predictive biomarker Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 229
release of cytokines in response to infection or trauma. 2. Glissmeyer M. Reviewing prognostic factors in Patients generally have no complaints as well as clinical breast cancer management. JAAPA. 2007;20(5):42– symptoms are not always found and only present in 30% 6. of patients are thrombohemorrhagic events. Besides that, 3. Asano Y, Kashiwagi S, Onoda N, Noda S, Kawajiri you can also find complaints of headaches, dizziness, H, Takashima T, et al. Platelet-Lymphocyte Ratio paresthesia and facial phenomena. as a Useful Predictor of the Therapeutic Effect of Neoadjuvant Chemotherapy in Breast Cancer. Conclusion PLoS One. 2016;11(7):e0153459. There was a significant relationship between 4. Cuello-López J, Fidalgo-Zapata A, López- an increase in the platelet / lymphocyte ratio with a Agudelo L, Vásquez-Trespalacios E. Platelet-To- lymphocyte ratio as a predictive factor of complete decrease in the response to chemotherapy neoadjuvant pathologic response to neoadjuvant chemotherapy CAF in Locally Advanced Breast Cancer patients, where in breast cancer. PLoS One. 2018;13(11):112. the higher the platelet / lymphocyte ratio, the lower the response to chemotherapy neoadjuvant CAF 5. Kim HY, Kim TH, Yoon HK, Lee A. The role of neutrophil-lymphocyte ratio and platelet- Ethical Clearance: Taken from Dr. Soetomo lymphocyte ratio in predicting neoadjuvant General Hospital Ethical, Research, and Development chemotherapy response in breast cancer. J Breast Committee. Cancer. 2019;22(3):425–38. 6. Zhang M, Huang XZ, Song YX, Gao P, Sun JX, Source of Funding: Self Wang ZN. High Platelet-to-Lymphocyte Ratio Predicts Poor Prognosis and Clinicopathological Conflict of Interest : Nil Characteristics in Patients with Breast Cancer: A Bibliography Meta-Analysis. Biomed Res Int. 2017;2017. 7. Zhu Y, Si W, Sun Q, Qin B, Zhao W, Yang J. 1. Tryfonidis K, Senkus E, Cardoso MJ, Cardoso F. Platelet-lymphocyte ratio acts as an indicator of Management of locally advanced breast cancer— poor prognosis in patients with breast cancer. perspectives and future directions. Nat Rev Clin Oncotarget. 2017;8(1):1023–30. Oncol [Internet]. 2015;12(3):147–62. Available from: https://doi.org/10.1038/nrclinonc.2015.13 230 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13854 Social Aspects of Unwanted Teen Pregnancy Management: a Case Report
Noviana Ingmiati Tjung1, Arnold Kabaria Serworwora2, Kevin Yonathan1 1General Practitioner, Kediri Baptis Hospital, Kediri, Indonesia, 2 Obstetrician and Gynaecologist, Kediri Baptis Hospital, Kediri, Indonesia
Abstract
Background: Teenage pregnancy is an increasing problem worldwide. It correlates with higher rate of maternal and perinatal morbidity and mortality. Social issues would complicate the management by delaying therapy, stigmatization of the patients, and even initiation of child abuse. This study aims to present a case of unwanted teen pregnancy in which social aspect plays a significant role of its outcome.
Case: A case of 17-years-old unmarried woman came due to abdominal pain and abnormal uterine bleeding. She had pregnancy test prior to the admittance with positive result. Her family found out about the test and forced her to come to emergency ward in order to confirm the pregnancy. Examinations showed that she had ruptured ectopic pregnancy, bilateral pyosalpinx, and endometrial thickening. Bilateral salpingectomy and curettage was done. The patient chose to delay having treatment due to fear of being found out by the family. Teenage pregnancy is an arising health, economical, and social problem in Indonesia. In addition to higher risk of morbidities and mortalities, it is also aggravated by social stigma of having extramarital sex. Family support plays pivotal role in determining the outcome of teenage pregnancy.
Conclusion: Teenage pregnancy is a complex problem requiring comprehensive and multidiscipline management on physical, psychological, and social aspects. Social problems would aggravate the situation, potentially delay the management and exacerbate the outcome
Keywords: Teenage pregnancy, unsafe abortion, unwanted pregnancy.
Introduction rate of maternal and perinatal morbidity and mortality.1
Teenage pregnancy is an increasing problem In developing countries, teenage and unmarried over past decade. Earlier onset of puberty coupled by pregnancy directly impacts the rate of child marriage. shifting sociocultural environment increases the amount It is estimated that 39,000 child marriages happen each of premarital sex, both in developing and developed day worldwide.3 It is a complex problem requiring 1 countries. Indonesia as one of the developing countries management on physical, psychological, and social also experiences the problem with increasing teenage aspects. Oftentimes, social aspect would complicate pregnancy, albeit having one of its law protecting management, such as delay in therapy due to social children aged under 18 years old against teenage issues arising in the family. pregnancy.2 Teenage pregnancy correlates with higher This study aims to present a case of unwanted teen pregnancy in which social aspect plays a significant role Corresponding author of its management. Dr. Noviana Ingmiati Tjung Brigjend Pol. IBH Pranoto No.1-7, Bangsal, Kec. Case Pesantren, Kota Kediri, Jawa Timur 64131 Phone number: +6281259997710 17-year-old G1P0 unmarried woman came to the th E-mail: [email protected] emergency unit of Baptis Hospital Kediri at 25 of Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 231
January 2020 with chief complaint of dull pain at the right Following the meeting, transvaginal ultrasound (US) upper quadrant of her abdomen from a week ago. There examination was done with family consent. The results was no complaint of urinating or defecating problem of US exam were right periovarian mass sized 4.79 cm neither abnormal vaginal discharge at the moment. x 2.68 cm suspected to be ruptured ectopic implantation, The first day of patient’s last menstruation was about 6 enlarged left ovary, and endometrial thickening. We weeks ago, but patient said that she had another bleeding informed the family that it was likely that the patient had outside her regular period about 2 weeks ago. According ruptured ectopic pregnancy, thus emergency surgery to the patient, the bleeding felt a little bit different as the in order to evacuate the mass was imperative in order blood was considerably ample, darker, and thicker than to prevent heavy bleeding and avoid death. We also her usual period. The bleeding had been occurring for 2 informed that the surgery might be continued to unilateral days followed by pain in abdomen about a week after. or bilateral salpingectomy, supposedly rendering the Urine examination was done voluntarily 3 days prior patient to be infertile. Additionally, curettage would to ER admission, of which result of urine examination be required due to endometrial thickening further was within the normal limit, and the pregnancy test was complicating the condition. positive. Hearing the result and probable management, her Previously, she had her first menarche at the age mother and brother were furious. They accused her of of 12, each ranging about 5-6 days, routinely changing adultery and said that her condition was “divine’s wrath” pads 2-3 times each day, without any pain. Patients vital due to her sins. The doctors and nurses told the family sign was stable at the time of arrival. Mild abdominal that the situation was not appropriate for blaming each pain was present at the right upper quadrant radiating to other. After regaining composure, her family approved her back at general physical examination. the surgery and signed the consent paper.
Complete blood count, urine examination, and After having consent from the patient and her pregnancy test were completed at the ER. Her blood result guardian, an emergency explorative laparotomy was was hypochromic microcytic anemia with increased planned with the possibility of having unilateral RDW and normal leucocyte level. Urine examination salpingectomy followed by curettage. During the result was within normal limit while pregnancy test was surgery, the left fallopian tubes was found to be dilated found to be negative. while the right fallopian tube was found to be ruptured, both producing about 5 cc of purulent discharge. The An emergency family meeting consisting of the diagnosis was determined as ruptured ectopic pregnancy obstetrician, emergency doctor, emergency nurse, the with bilateral pyosalpinx. Considering intraoperative patient, her parents, and her older brother was carried finding, bilateral salpingectomy was done. Following the out on emergency ward. The family insists that another surgery, curettage was executed. The specimens from pregnancy test was done in order to verify whether the surgery and curettage were sent for histopathological the patient had already done sexual intercourse before examination. marriage. Her older brother also said that she might be punished for bringing shame to the family, should One week following the procedure, the results of she was actually pregnant. The patient, terrified of her histopathological examination showed bilateral tubal family, told the doctors that she had already known abscess with fibrotic tissue and bloody discharge, and that she was pregnant. However, she delayed seeking remains of conception on the right fallopian tube, without medical treatment in order to not letting her family any sign of malignancy. On her postoperative visit, the found out because then she would be “beaten to death”. patient was accompanied by her mother. The patient Instead, she came to several clinics and performed and her family said that they had already accepted the voluntary laboratory tests. The only reason she came to condition. the emergency ward was her parents found out about her laboratory results incidentally. Discussion Teenage pregnancy or adolescent pregnancy is 232 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
a complex problem in health, social, and economy would result in induced abortion.9 On the contrary, problem. In USA at the year 0f 2010, approximately 3.4 supportive parents would ameliorate both maternal and percent of births come from mother at the age of 15- perinatal outcome. Research in Central Java showed 19.4 Its prevalence in Indonesia has been rising since the that most of teenage mothers would be helped by their last decade, reaching 48 per 1,000 pregnancy.5 Problems parents, especially during postpartum period.10 In this arising from teenage pregnancy include increased unfortunate case, the patient had severe fear of her maternal and perinatal morbidities and mortalities, poor family knowing about her pregnancy, leading to delay health habit, malnutrition, poverty, lower education in management and worse outcome. After knowing level, and social labelling.1,6 the condition, her family also condemn the patient as receiving “divine’s wrath’ due to her sins, exacerbating Previous research in Jakarta showed that teenage the situation. pregnancy has higher risk of anemia at labor, preterm delivery, postpartum hemorrhage, low birth weight, and Iatrogenic infertility induced by the management eclampsia.7 There are numerous factors contributing to of patient’s condition also created new problems. In increased rate of adverse event in teenage pregnancy, Indonesia, infertile women as viewed as “not whole” including imperfect anatomical and hormonal function, as they are unable to provide decent offspring for the lower hygiene, and lower socioeconomical status.7 family.6 This would also hinder the patient’s ability to search for a partner in the future. In religious countries, unmarried pregnant teenagers are often stigmatized by both families and communities Realizing the complex problem and situation of as “spoiled” or “filthy” due to having extramarital sex. teenage pregnancy, it is imperative that multisectoral This social phenomenon would lead into early marriage action is initiated to address the problem. As primary or abortion attempt, often self-induced or unsafe. prevention, previous research has found that combination Moreover, unmarried pregnant teenagers would later of widespread health education and contraceptive have difficulties in searching for partner, constructing a promotion would be useful. Moreover, all teenage label as an “unwanted”.6 pregnancy patients should be consulted for potential abuse and child protection issues. Contraceptive Family plays a pivotal role in determining the education should also be delivered for already pregnant outcome of adolescent pregnancy. Previous research in teenagers in order to reduce the rate of repeated teenage Indonesia had shown that women with lower educational pregnancy.9 However, intervention only from clinicians level and ambiguous family structure would have higher would not be sufficient. Research conducted on East Java risk of having teenage pregnancy.5 Conflicts occurring showed that risk of teenage pregnancy is determined in family would also impair psychological development by education, socioeconomical status, and age.11 in children, thus affecting sexual behavior.5 Another Comprehensive management from multidiscipline and particular issue in Indonesia is its rarity of sexual matter multisectoral profession would be required to deal with discussion among family. Most of the families regard the complex problems of teenage pregnancy. sex as a “taboo” and should not be discussed.8 Conclusion Following unwanted pregnancy, only a few of the teenagers would actually disclose voluntarily to their Teenage pregnancy is a complex problem requiring parents. Based on previous research in Central Java, comprehensive and multidiscipline management on most of them were worried of having social stigma, physical, psychological, and social aspects. Social afraid of disappointing their parents, or even afraid of problems would aggravate the situation, potentially getting dropped-out from school.8 It is not uncommon delay the management and exacerbate the outcome. that women with teenage pregnancy to be beaten by Support from partner, family, dan clinicians would be their family. This would also create another problem as beneficial to improve the outcome for both the mother the appropriate antenatal care for the patient would be and the baby. delayed or even resulting in unsafe abortion.8 Previous data from UK also showed that half of teenage pregnancy Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 233
Acknowledgement: Authors would also like to adolescent pregnancy in Surabaya, Indonesia. Maj extend special thanks to our parents and family for Obs Gin. 2018; 26(2): 91-97. academical guidance and psychological supports. 6. Asriani DD. The Unmarried Pregnant Girls’ Voices and Body Politics Surrounding The Girlhood Authors declare that there is Conflict of Interest: in Yogyakarta Indonesia. Seoul: Ewha Woman no conflict of interest in this study. University Repository; 2020. Ethical Clearance: The ethical clearance was 7. Indart J, Fattah ANA, Dewi Z, Hasani RDK, Mahdi issued by the Committee of Ethical Research in Kediri FAN, Surya R. Teenage Pregnancy: Obstetric and Baptis Hospital, Kediri, Indonesia. Perinatal Outcome in a Tertiary Centre in Indonesia. Obstet Gynecol Int. 2020; 1(1): 1-5. Source of Funding: All of the funding for this study 8. Aprianti, Shaluhiyah Z, Suryoputro A. Self- was fulfilled by the authors. Disclosure of Adolescents about Unwanted Pregnancy to Their Partners and Parents: A References Qualitative Study in Cetral Java Indonesia. Jawa 1. Soejoenoes A. Teenage Pregnancy. Indones J Tengah: Science and Technology Publications; Obstet Gynecol. 2017; 5(3): 128-129. 2018. 2. Dewan Perwakilan Rakyat Republik Indonesia. 9. Rohmah N, Yusuf A, Hargono R, Laksono AD, Undang – Undang Republik Indonesia Nomor Masruroh, Ibrahim I, Walid S. Determinants of 35 Tahun 2014 Tentang Perubahan Atas Undang Teenage Pregnancy in Indonesia. Indian J Forensic – Undang Nomor 23 Tahun 2002 Tentang Med Toxic; 2020: 14(3): 2080-2085. Perlindungan Anak. Jakarta: Dewan Perwakilan 10. Cook SMC, Cameron ST. Social issues of teenage Rakyat Republik Indonesia; 2014. pregnancy. Obstet Gynecol Reprod Med. 2017; 27 3. World Health Organization. Child marriages: 39 (11): 327-332. 000 every day. [internet]. 2013 (cited 2020 Jul). 11. Khuzaiyah S. The Effort of Caring Baby during Available from: https://www.who.int/mediacentre/ Pregnancy and Early Childbirth among Teenage news/releases/2013/child_marriage_20130307/en/ Mothers with an Unwanted and an Unmarried 4. Cunningham FG, Leveno KJ, Bloom SL, Dashe JS Pregnancy: A Qualitative Study. In: Proceedings , Hoffman BL, Casey, et al. Williams obstetrics. of International Seminar: Elevating Quality of 25th ed. New York: McGraw-Hill Education; 2018. Early Childhood Education and Care [conference proceedings on the Internet]; 2019; Makassar: 5. Anifah F, Dasuki D, Fitriana HK, Triratnawati Universitas Muhammadiyah Prof Dr. Hamka; A. Role of family structure and parenting style in 2020. 234 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13855 Association of Patient Characteristics with in Vitro Fertilization (IVF) Failure in Graha Amerta Fertility Clinic Dr. Soetomo General Hospital, Surabaya
Ashon Sa’adi1, Wigaviola Socha Purnamaasri Harmadha2, Ni Wajan Thirtaningsih3, Hamdani Lunardhi4 Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, 2Faculty of Medicine, Universitas Airlangga, 3Department of Anatomy and Histology, Faculty of Medicine, Airlangga University, 4Department of Biomedical Science, Faculty of Medicine, Airlangga University
Abstract Background : Due to the development of science and technology in the field of medicine, infertility has been solved by the discovery of one of the most sophisticated ART program, known as IVF. Although this procedure has been carried out for more than 40 years, the failure rate is still very high. This problem is considered to be related with the characteristic of the patient undergoing IVF. This study aims to determine the association between patient’s multi-characteristics and IVF failure.
Method : This research is an observational analytic research with cross-sectional method. The determination of the research sample uses a total sampling technique by taking all members of the population in accordance with the conditions.
Result : Out of 102 couples undergoing IVF, 37 couples (36,3%) successfully obtained a pregnancy while the 65 other couples (63,7%) failed IVF or has not obtained a pregnancy. The result of the p value between IVF failure and maternal age is 0,03, with BMI 0,532, with sperm quality 0,577, with PCOS 0,297, with endometriosis 0,578, and with POR 0,027.
Conclusion : Out of all the studied patient characteristics, only maternal age and POR are associated with IVF failure with the p value of 0,03 and 0,027 respectively. BMI, sperm quality, PCOS, and endometriosis do not show a significant correlation with IVF failure.
Keywords : IVF Failure, Age, BMI, Sperm quality, PCOS, Endometriosis, POR.
Introduction back into the uterus of the infertile woman so that it develops into pregnancy1. IVF success was first marked The factors that cause infertility can come from by the birth of Louisa Brown in 1978. The success of IVF both men and women. However, by the development is growing rapidly where the initial implantation rates of science and technology in the field of medicine, that were <5% per embryo replaced were continuously infertility has been solved by the discovery of the most increased to rates >50%2. Therefore, until now, IVF sophisticated Assisted Reproductive Technology (ART) has helped many couples who cannot experience their program, known as In Vitro Fertilization (IVF). In IVF, pregnancy naturally. the fertilized embryo from outside of the uterus is placed Although IVF has been carried out for more than 40 Corresponding author: years, the failure rate is still very high. This problem is Ashon Sa’adi, dr, SpOG (K) considered to be related with the characteristics of the Department of Obstetrics and Gynecology, Faculty of patient undergoing IVF. Of the 2552 IVF cycles that had Medicine, Universitas Airlangga, Dr. Soetomo General been carried out, only 31.2% of the 7213 eggs that were Hospital +628170121121, [email protected] plucked were successful in becoming good embryos so Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 235
that it can be used in IVF. This fact is reinforced by data study were all couples who underwent IVF in Graha showing that only 5% of the 7213 eggs successfully Amerta Fertility Clinic Dr. Soetomo General Hospital become babies, so the success rate is still very low 3. from July 2018 to July 2019. Using ordinal data from IVF is considered to be a failure if it does not lead to patients’ medical record, patient characteristics data on pregnancy, which is indicated by the level of Beta HCG age, BMI, sperm quality, PCOS, endometriosis, POR, in the blood. If the Beta-HCG level exceeds 25 mIU mL, and b-hCG levels were obtained and analyzed. A total it is stated that pregnancy has occurred, and vice versa. of 102 couples who underwent IVF were included in this study. There are two groups of patient, which are There are three important stages during IVF that patient who succeed to obtained pregnancy and those has a great role in determining its success. These first who failed. From age characteristic, the female partners type of factors is known as the internal factor, namely: are divided into three groups: 25-35 years; 36-40 years; (1) the ovulation induction; (2) the fertilization; and and >40 years. The BMI were categorized into four (3) the Embryo Transfer (ET). Apart from the internal group: <18,5 kg/m2; 18,5-24,9 kg/m2; 25-29,9 kg/m2; factors, there are also external factors such as patient 30 kg/m2. The sperm quality was determined by characteristics that can cause IVF failure.{Formatting the sperm analysis results data. POR was diagnosed by Citation} Patient characteristic factors include the age the guidelines from the European Society of Human of the female partners. Post-IVF cumulative pregnancy Reproduction and Embryology (ESHRE), which is if success rate varies with age, where in the 20-24 years two of the these characteristics are present: (1) Maternal age range it is 40% while in the 40-45 years age range Age >39; (2) a previous POR which is the retrieved it is 20%. Patient with obesity (BMI> 30 kg/m2) has a oocyte were under 4; and (3) ovarian reserve test result greater risk of implantation failure than patients with was abnormal (AFC <5–7 follicles) or AMH < 0.5–1.1 normal BMI (18.5-24.9 kg/m2). For male patients, sperm ng/mL)6. Patients with discontinuation status who had quality have an influence on the success of fertilization. not completed the cycle, canceled cycle and incomplete The presence of endometriosis and a history of other data were not included in this study. Ethical clearance uterine diseases can affect the success rate of embryo was granted by the Health Research Ethics Committee implantation, due to changes in secretory components Faculty of Medicine, Universitas Airlangga. and endometrial thickness4. PCOS are also associated with the quality of the oocytes obtained. Furthermore, The data of samples were not distributed normally, the existence of Poor Ovarian Reserve (POR) disease therefore, data normality test is not required. With non- has an effect on the least number of oocytes produced. parametric statistical tests, analyses were performed Some studies have also suggested that there is a twofold using the Chi-square test and Fisher’s Exact Test on increased risk of miscarriage in women with thyroid SPSS software. Statistical significance were determined dysfunction5. if p <0,05 and the strength of the relationship between two variables were showed from the Contingency IVF failure can cause various problems for couples. Coefficient (C). With the magnitude of the negative impacts that can occur due to the failure of the IVF program, further Results studies are needed regarding the correlation of patient A total of 214 medical records were obtained multi-characteristic with IVF failure at Graha Amerta and only 102 of them were eligible for this study. Fertility Clinic Dr. Soetomo General Hospital so that it 102 couples underwent IVF were observed and only can be useful to optimize the pregnancy rate. 37 couples (36,3%) succeeded to obtain pregnancy, Methods whereas the other 65 (63,7%) failed. The association of patient characteristics with IVF failure at Graha Amerta This research is an observational analytic research Fertility Clinic Dr. Soetomo General Hospital in the with cross-sectional method. The samples in this 2018-2019 period is shown in table 1 below. 236 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table I. Characteristics associated with IVF failure Succeed IVF group Failed IVF group (n=65) Characteristics (n=37) P value n % n %
Age (years) 0,03
25-35 32 86,5% 43 66,2%
36-40 5 13,5% 13 20%
>40 0 0% 9 13,8%
BMI (kg/m2) 0,556
<18,5 1 2,7% 4 6,2%
18,5 – 24,9 25 67,6% 36 55,4%
25 – 29,9 7 18,9% 19 29,2%
≥ 30 4 10,8% 6 9,2%
Sperm quality 0,577
normal 10 27% 21 32,3%
abnormal 27 73% 44 67,7%
PCOS 0,297
non-PCOS 35 94,6% 64 98,5%
PCOS 2 5,4% 1 1,5%
Endometriosis 0,578
non-Endometriosis 34 91,9% 59 90,8%
Endometriosis 3 8,1% 6 9,2%
POR 0,027
non-POR 34 91,9% 48 73,8%
POR 3 8,1% 17 26,2%
BMI : Body Mass Index; E2 :Estradiol; IVF: In Vitro Fertilization; POR :Poor Ovarian Reserve; PCOS :Polycystic Ovary Syndrome.
Age and POR characteristics shows a p value of 0,03 and 0,027 respectively. Both characteristics show a significant association with IVF failure (p <0,05).Characteristics associated with IVF significantly were showed in table II with Contingency Coefficient value C).( Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 237
Table II. Contingency Coefficient analysis of characteristics with IVF failure
Succeed IVF group (n=37) Failed IVF group (n=65) Characteristics C n % n %
Age (years) 0,254
25-35 32 86,5% 43 66,2%
36-40 5 13,5% 13 20%
>40 0 0% 9 13,8%
POR 0,213
non-POR 34 91,9% 48 73,8%
POR 3 8,1% 17 26,2%
C : Contingency Coefficient; POR: Poor Ovarian Reseve.
Discussion Hospital 2004-2014 on the percentage of pregnancies in a group of women: 43.3% for 19-29 years old; 48.8% From the previous study, it is reported that only 5% for 30-39 years old; 5.2% for 40-44 years old; and the of the 7213 eggs successfully become babies. In line smallest percentage of successful pregnancy at 0.34% with the high failure rate of IVF cycles in Indonesia, for women aged over 45 years old7. Another study was it is important to evaluate the process for a maximum done by Coughlan et al., which showed similar results outcome. Although several reports have been conducted that explained the negative effect of age on embryo worldwide, studies in Indonesia are still very much quality in IVF. This is related to the risk of aneuploidy needed. This article mentioned the association between which increases with age8. Dicker et al. also found a age, BMI, sperm quality, PCOS, endometriosis, and lower IVF success rate at women aged over 40 with p POR characteristics with IVF failure. value of <0,059. A different study in 2014 by Hendarto Most of the couple underwent IVF in Graha Amerta showed that there is a significant different of oocyte Fertility Clinic Dr. Soetomo General Hospital from count in a group of age < 35 and ³ 35 (p< 0,05)10. The July 2018 to July 2019 failed to obtained pregnancy. association between age and IVF failure is explained by From 102 couples, only 37 (36,3%) succeeded to obtain Saphiro et al. in 2016, which explains that the uterus of pregnancy which is categorized as the successful IVF elderly women has decreased vascularity, endometrium group. Couples that succeed IVF were mostly aged thickness, and prostaglandin production which are around 25-35 with no reported success among the related to embryo implantation11. observed samples at age over 40. From the statistical BMI characteristics were reported to have a negative calculations, age characteristics with IVF failure were impact on determining IVF success. Previous study by associated significantly (p <0,05) with Contingency Comstock et al. showed significant results with p value Coefficient of 0,254. The results described above verify of 0,007 between BMI and IVF success. Comstock et the findings of a previous study in Berlin by Rendtorff et al. stated that the rate of blastocyst formation in women al. in 2016 which presented data from Charite University with normal weight was significantly better than in 238 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
obese women12. This reason leads to the influence of showed that there was no significant difference. oocyte quality on embryo development in obese women The characteristics of endometrium where the which ultimately predisposes to IVF failure. The result implantation will occur have a significant role in in this study was contradictory with a previous study determining IVF success. In this study, statistical test was (p <0,556). The dissimilar results of these studies can performed between endometriosis characteristic and IVF be caused by many factors. Various factors during the failure and the result was insignificant with p value of process of carrying out the procedure such as expert skills 0,578. This result was not in line with a previous study17 and the technology used also have a very important role which explained that endometriosis was associated in determining IVF outcome, which in this study was not significantly with IVF failure with p value <0,001. This examined so that it affects the final result. Another factor result was obtained by analyzing the data showing that that affects IVF outcome is the characteristics of men, IVF success rate in women with endometriosis were one of which is the quality of sperm which is different only 50% compared to non-endometriosis women. This for each patient. contradiction could be affected by many factors and In order to have a successful IVF and obtain further research is needed. pregnancy, the male partners have a primary role in giving Other characteristics studied in this research was the sperm cell that is going to fertilize the oocyte. In this POR. Women with POR are likely to fail the IVF. study, most of the couple that were successful in IVF have We found a significant association between POR normal sperm cells in terms of morphology, motility, characteristics with p value of 0,027. This result and amount. From the statistical calculations, we found confirms the previous study by Jirge in 2016 which insignificant result with p value of 0,577 between sperm explained that POR is one of the most important factors quality and IVF failure. This result is contradictory with that affect IVF success6. It is stated that 10% of women the previous study that states sperm cells must be able to with POR showed a weak response from gonadotropin carry out its function to penetrate zona pellucida in order stimulations. Another study conducted by Yun et al. in to fertilize the oocyte13. However, men with abnormal 2017 showed a significant association between POR and sperm characteristic are unable to do that, which leads IVF failure with p value of 0,01918. to IVF failure. Another study by Respati explained that embryo quality is affected by sperm quality and there is a This study has several limitations such as small significant correlation between embryo quality and IVF sample size and lacking data on medical records. The 14 failure . This contradictory result is affected by many aforementioned limitations may contribute to our data factors, and it is assumed that the severity of abnormal that indicating different results with the previous studies. sperm could affect IVF failure. ART procedure on each stage were not assessed in this study, and further research is needed with more specific We also studied the association of PCOS inclusive criteria and bigger sample size. characteristic with IVF failure. Statistical test was conducted and the results show an insignificant p value Conclusion of 0,297. This result was not in line with a previous study in China by He et al. in 2019 which stated that PCOS has Age and POR characteristics were associated with a negative effect on IVF15. Similar results were observed IVF failure significantly. Other Characteristics such in a study conducted by McCormick et al16. The results as BMI, sperm quality, endometriosis, and PCOS did showed that there was no statistically significant effect not show significant results. However, characteristics of women with PCOS towards IVF failure. McCormick described above should be a consideration in patient et al. conducted a study on obese women which are who planned to have an IVF treatment. divided into two groups, namely obese women with Article notes PCOS and obese women without PCOS16. The analysis results of the study explained that there was a decrease Conflict of InterestThe authors declare no conflicts in the implantation rate in obese women with PCOS, but of interest in preparing this article the end result or pregnancy of IVF in the two groups Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 239
Source of Funding This research received no 7. Rendtorff R, Hinkson L, Kiver V, Dröge LA, specific grant from any funding agency in the public, Henrich W. Pregnancies in Women Aged 45 Years commercial, or not-for-profit sectors. and Older - a 10-Year Retrospective Analysis in Berlin. Geburtshilfe Frauenheilkd. 2017 Ethical Clearance: Taken Mar;77(3):268-275. doi: 10.1055/s-0043-100105. PMID: 28392580; PMCID: PMC5383433. References 8. Coughlan C, Ledger W, Wang Q, Liu F, Demirol 1. Lopata A. Concepts in human in vitro fertilization and A, Gurgan T, Cutting R, Ong K, Sallam H, Li embryo transfer. Fertil Steril. 1983 Sep;40(3):289- TC. Recurrent implantation failure: definition 301. doi: 10.1016/s0015-0282(16)47289-4. PMID: and management. Reprod Biomed Online. 2014 6350050. Jan;28(1):14-38. doi: 10.1016/j.rbmo.2013.08.011. 2. Niederberger C, Pellicer A, Cohen J, Gardner DK, Epub 2013 Sep 14. PMID: 24269084. Palermo GD, O'Neill CL, Chow S, Rosenwaks 9. Dicker D, Goldman JA, Ashkenazi J, Feldberg D, Z, Cobo A, Swain JE, Schoolcraft WB, Frydman Shelef M, Levy T. Age and pregnancy rates in in R, Bishop LA, Aharon D, Gordon C, New E, vitro fertilization. J In Vitro Fert Embryo Transf. Decherney A, Tan SL, Paulson RJ, Goldfarb JM, 1991 Jun;8(3):141-4. doi: 10.1007/BF01131703. Brännström M, Donnez J, Silber S, Dolmans MM, PMID: 1919259. Simpson JL, Handyside AH, Munné S, Eguizabal 10. Hendy Hendarto, 090315218 D (2014) PERAN C, Montserrat N, Izpisua Belmonte JC, Trounson USIA DAN LAMA INFERTILITAS TERHADAP A, Simon C, Tulandi T, Giudice LC, Norman RJ, JUMLAH OOSIT YANG DIDAPAT PADA Hsueh AJ, Sun Y, Laufer N, Kochman R, Eldar- PROGRAM FERTILISASI IN VITRO (The Geva T, Lunenfeld B, Ezcurra D, D'Hooghe T, Role of Advanced Age and Duration of Infertility Fauser BCJM, Tarlatzis BC, Meldrum DR, Casper on Oocyte Number Retrieved during In Vitro RF, Fatemi HM, Devroey P, Galliano D, Wikland Fertilization). Jurnal Ners, 9 (2). pp. 183-186. ISSN M, Sigman M, Schoor RA, Goldstein M, Lipshultz 1858-3598 LI, Schlegel PN, Hussein A, Oates RD, Brannigan 11. Shapiro BS, Daneshmand ST, Desai J, Garner RE, Ross HE, Pennings G, Klock SC, Brown S, Van FC, Aguirre M, Hudson C. The risk of embryo- Steirteghem A, Rebar RW, LaBarbera AR. Forty endometrium asynchrony increases with maternal years of IVF. Fertil Steril. 2018 Jul 15;110(2):185- age after ovarian stimulation and IVF. Reprod 324.e5. doi: 10.1016/j.fertnstert.2018.06.005. Biomed Online. 2016 Jul;33(1):50-5. doi: PMID: 30053940. 10.1016/j.rbmo.2016.04.008. Epub 2016 Apr 22. 3. WIWEKO, B.. Inovasi Kedokteran Reproduksi PMID: 27178763. di Era Disrupsi. eJournal Kedokteran Indonesia, 12. Comstock IA, Kim S, Behr B, Lathi RB. Increased North America, 6, jan. 2019. body mass index negatively impacts blastocyst 4. Penzias AS. Recurrent IVF failure: other factors. formation rate in normal responders undergoing Fertil Steril. 2012 May;97(5):1033-8. doi: in vitro fertilization. J Assist Reprod Genet. 2015 10.1016/j.fertnstert.2012.03.017. Epub 2012 Mar Sep;32(9):1299-304. doi: 10.1007/s10815-015- 28. Erratum in: Fertil Steril. 2013 Jan;99(1):297. 0515-1. Epub 2015 Jun 25. PMID: 26109331; Erratum in: Fertil Steril. 2013 Jan;99(1):297. PMCID: PMC4595387. PMID: 22464759. 13. Esteves Sandro C., Miyaoka Ricardo, Agarwal 5. Sarkar D. Recurrent pregnancy loss in patients with Ashok. An update on the clinical assessment of the thyroid dysfunction. Indian J Endocrinol Metab. infertile male. Clinics [Internet]. 2011; 66( 4 ): 2012 Dec;16(Suppl 2):S350-1. doi: 10.4103/2230- 691-700. 8210.104088. PMID: 23565424; PMCID: 14. RESPATI, GIRL. KEBERHASILAN PROGRAM PMC3603072. FERTILISASI IN VITRO DI KLINIK 6. Jirge PR. Poor ovarian reserve. J Hum Reprod INFERTILITAS FK UNDIP- RS Dr KARIADI Sci. 2016 Apr-Jun;9(2):63-9. doi: 10.4103/0974- DAN RS TELOGOREJO SEMARANG. (2005) 1208.183514. PMID: 27382229; PMCID: Masters thesis, program Pascasarjana Universitas PMC4915288. Diponegoro. 240 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
15. He Y, Lu Y, Zhu Q, Wang Y, Lindheim SR, Qi 18191852. J, Li X, Ding Y, Shi Y, Wei D, Chen ZJ, Sun Y. 17. Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect Influence of metabolic syndrome on female fertility of endometriosis on in vitro fertilization. Fertil and in vitro fertilization outcomes in PCOS women. Steril. 2002 Jun;77(6):1148-55. doi: 10.1016/ Am J Obstet Gynecol. 2019 Aug;221(2):138.e1- s0015-0282(02)03112-6. PMID: 12057720. 138.e12. doi: 10.1016/j.ajog.2019.03.011. Epub 18. Yun BH, Kim G, Park SH, Noe EB, Seo SK, Cho 2019 Mar 22. PMID: 30910544. S, Choi YS, Lee BS. In vitro fertilization outcome 16. McCormick B, Thomas M, Maxwell R, Williams in women with diminished ovarian reserve. Obstet D, Aubuchon M. Effects of polycystic ovarian Gynecol Sci. 2017 Jan;60(1):46-52. doi: 10.5468/ syndrome on in vitro fertilization-embryo transfer ogs.2017.60.1.46. Epub 2017 Jan 19. PMID: outcomes are influenced by body mass index. Fertil 28217671; PMCID: PMC5313363. Steril. 2008 Dec;90(6):2304-9. doi: 10.1016/j. fertnstert.2007.10.077. Epub 2008 Jan 14. PMID: DOI Number: 10.37506/ijphrd.v12i1.13856 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 241 Trend of Traffic Accident From 2012 Until 2016 Based on The Accident Report Data and Police Investigation Report in Bogor City
Bunga Oktara Lecturer, Department of Public Health, STIKes Wijaya Husada, Bogor
Abstract Background: World Health Organization (WHO) declared a traffic accident could claim about 1,2 million human lives every year and the injured or disabled victim could reach more than 50 million people. Preliminary study results in from Bogor City Police Department showed that there was an increase in traffic accidents by 100 accidents in 2015 to 148 accidents in 2016.
Aim: The purpose of this research is to investigate the trend of traffic accident during five years from 2012 until 2016 based on the accident report data and Police Investigation Report of traffic accident from Bogor City Police Department.
Methodology: The type of this research is descriptive quantitative by using secondary data. The method of taking sample in this research is using total sampling technique with the amount of sample 609.
Results: The trend of traffic accidents increased from 2012 to 2014 and from 2015 to 2016, decreased from 2014 to 2015.
Conclusion: The most common accidents occured in the type of motorcycle vehicle with male riders, aged between 12 years to 25 years, work as private employee, and have a high school education background. The most common types of accidents are double at two-way locations at 18.01-24.00 with the impact of injuries and caused by unskilled drivers.
Keywords: Accident, Traffic, Trend, Police investigation report
Introduction The preliminary study conducted at Bogor City Police showed that there was an increase in traffic Traffic accidents in Indonesia in 2009 reached accidents by 100 accidents in 2015 to 148 accidents in 33,827 people where 36% (12,178 people) died. This 2016 due to an increase in the number of vehicles each figure is very worrisome because among the 100 people year. who had an accident 36 people died and almost 50% of the victims were men from the productive age group. Methodology This results in a massive decrease in productivity.1 This research is a descriptive quantitative research, using secondary data based on accident report data and Corresponding Author: Police Investigation Report of Bogor City during 2012 Bunga Oktara, M.Kes. - 2016 to see traffic accident trend for the last 5 years . Department of Public Health STIKes Wijaya Husada This research was conducted at Police Department Jl. Ibrahim Adjie No. 180 of Bogor City, Accident Records Division from August Sindang Barang, Bogor, West Java, Indonesia 2016 to May 2017. The population in this research Email: [email protected] was motorists who experienced the incident of traffic 242 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
accidents in Bogor City from 2012 until 2016 which amounted to 609 cases of accidents. Total samping technique was used and the number of samples was equal to the population which amounts to 609 cases of accident.2
The variable in this research was traffic accident incident in Bogor City area from 2012 until 2016. Data analysis was obtained through univariate data analysis which aimed to explain the characteristics of research variables.3 Type of data used was secondary data, obtained from Police Investigation Report of Traffic Figure 3. Traffic Accidents Based on Gender Accident Bogor City Police Department. Further data Figure 3 is traffic accident data based on the gender analysis to see the trend of work accident was done by of motorists. There were 570 accidents happened in using Microsoft Excel. male motorists. The highest accident rate occurred in Research Result 2016 with 136 accidents in male motorists. m Figure 1. Trend Amount of Accidents
The number of incidents of traffic accidents in Bogor City was increased in 2012 until 2014 and in 2015 until 2016, while it was decreased in 2014 until 2015. The highest traffic accidents occured in 2016 as many as 148 traffic accidents.
Figure 2. Traffic Accident Based on Vehicle Type Figure 4. Traffic Accidents by Age Figure 2 is a traffic accident data that occurred based Figure 4 is a traffic accident data based on the on the type of vehicle from the year 2012-2016. There age of the motorists. Traffic accidents from 2012-2016 were 715 motorcycle accidents happened during four occured mostly in adolescents (12-25 years). The highest years while the highest accident rate was found in 2016 accident rate occurred in 2016 in the age group of 12-25 with 168 motorcycles accidents. years with 84 accidents. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 243
Figure 5. Traffic Accident Based on Background Education Figure 5 is traffic accident data based on educational background of motorists. The highest accident amount occurred in 2016 on a driver with a senior high school Figure 7. Unsafe Actions and Conditions Cause education background with total of 87 accidents. Traffic Accidents Figure 7 is a traffic accident data based on unsafe actions and conditions. Traffic accidents occurred on the basis of unsafe actions and conditions from 2012-2016 were mostly due to unskilled driver action with 228 accidents. The highest accident number was caused by unauthorized driver action occurred in 2016 as many as 53 accidents.
Discussion Figure 6. Traffic Accident Based on Impact Criteria The high incidence of traffic accidents in Bogor street. City was directly proportional to the growing number Figure 6 is a traffic accident data based on the of densely populated residents in Bogor City which impact criteria from 2012-2016 which was resulted in was also accompanied by the increase in the number of 428 accidents. The highest accident occurred in 2016 as vehicle ownership. Based on data from the Department many as 112 accidents causing injuries. of Road Traffic in 2012, the number of motor vehicles in Bogor reached 301,086 vehicles with motor vehicle growth increased by an average of 14.47% per year.
The incidence of traffic accidents started to increase in 2016. This condition was influenced by the increasing number of violation cases on motorists. During the implementation of zebra operations in 2016 cases of violations reached 19,475 with 72% of it including categories of serious violations or traffic violations that potentially result in fatal traffic accidents. This involved breaking the borders, exceeding the speed limit, no driver’s licence and violation of traffic signs. 244 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Other research by Dendy Wicaksono (2014) showed violated parking restrictions, contributed to 190 that the number of traffic accidents in motorcycles accidents during the five years period. It can be seen occupied the highest position compared to other four- that the this kind of drivers had lack of public awareness wheeled vehicles in Semarang city. This situation was toward traffic safety. Another contributing factor to the influenced by the number of motorcycle vehicles which accident was drowsiness. Drowsiness is a condition was greater than the number of other four-wheeled where the rider loses power and concentration due to vehicles that amounted up to 53.78% .4 lack of rest (sleep) and or has been driving more than 5 hours without rest. Motorcylists can also experience In terms of age of motorists with the most accidents sleepiness due to inhaling excessive carbondioxide gas. group was teenager group (12-25 years). This age group was productive age group with high mobility. Based on the results of research conducted by Other research results conducted by Sundari (2012) Akhmad David (2015), there was a relationship between mapped the age of teens most often experienced traffic driving behavior (human factor) and unkempt vehicle accidents. This is because adolescence is a period where (vehicle factor) with traffic accidents. Drivers’ bad emotions are overwhelming and it will impact behavior behavior can be caused by non-compliance with the of adolescents who tend to perform actions that violate rules on driving safety. The condition of the vehicle the rules.6 While globally according to WHO in both will affect the occurrence of traffic accidents. Good low-income countries and high-income teenagers group supervision and maintenance of vehicles will provide is the age group most often died from traffic accidents.7 safety on the road.9
Based on research conducted by Akhmad David The last unsafe condition that can cause traffic (2015) there was relationship between educational accidents is environmental conditions around the background with the incidence of traffic accidents. The occurrence of accidents, for example slippery road that lower level of motorists education level, the higher was caused by rain or oil spill. Environmental factor was traffic accident possibility.9 a factor that has the least number of accidents among other factors. Based on accident report data, the incident of traffic accidents usually occurred in low vehicle speed and the In the book Human Factors in Traffic Safety written resulted traffic accidents were not too severe. According by Robert E. Dewar and Paul L. Olson (2007), factors to the Bogor City Police Department, the impact of related to the occurrence of traffic accidents were traffic accidents was influenced by the speed ofthe divided into 3 such as: human factors, vehicle factors driver. When the driver drives his vehicle at high speed, and environmental factors.13 the level of driving difficulty increases which may result Based on the results of this research, the most in the driver’s inability to control his vehicle. dominating factor was human factor (driver). The Trend factors causing traffic accidents that occured second main cause was the vehicle factor and the least from 2012-2016 mostly involved the unskilled drivers. cause was environmental factors. This showed that The highest accident occurred in 2016 as many as 53 human factor played an important role in the occurrence accidents due to the attitude unskilled drivers. of traffic accidents.
Based on the results of research the unskilled driver If linked between these three factors, unsafe actions contributed to 228 accidents during the last 5 years. and conditions such as unskilled, physical environmental Unskilled drivers factor caused them unable to control conditions such as damaged roads or slippery roads and their vehicles properly. Therefore, it takes practice and unattended vehicle factors will be highly visible. In experience in driving so that the drivers will have the damaged roads or slippery roads, if motorists are not natural skills to face various traffic situations. highly skilled, then the rider will be difficult to avoid hollow road or maintain the balance. Irregular motorists, who crossed the speed limit, used the opposite lane, coud not mantain a safe distance, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 245
Conclusion 4. Wicaksono, D. et al. Analisis Kecelakaan Lalu Lintas (Studi Kasus – Jalan Raya Ungaran – 1. Trend of traffic accidents increases from 2012 Bawen). Jurnal Karya Teknik Sipil. 2014; 3(2):345- to 2014 and from 2015 to 2016, decreasing from 2014 to 355. 2015. 5. Putranto, L., Pramana,A., Kurniawan H. Hubungan 2. The type of vehicle that has the most traffic Antara Perilaku Pengemudi Sepeda Motor Pada accidents from 2012 until 2016 is a motorcycle vehicle. Berbagai Keadaan Lalu Lintas Jalan Dengan Karakteristik Pengemudi. 2016. 3. Characteristics of motorists based on the sex of 6. Sundari, N.P. Perilaku Pengendara Sepeda Motor the most frequent traffic accidents from 2012 to 2016 is Pada Remaja Terhadap Risiko Kecelakaan Lalu male. Lintas. 2009. Available from http://www. http:// repository.unair.ac.id/22394/1/gdlhub-gdl-s1- 4. Characteristics of motorists by age with the 2010-sundarinan-11551-fkm226-9.pdf. most traffic accidents from 2012 to 2016 is the age of 7. World Health Organization. Global Status Report adolescents (12-25 years). on Road Safety. 2013. Available from http://www. 5. Characteristics of motorists based on education who.int/violence_injury_prevention/road_safety_ that has the most traffic accidents from 2012 until 2016 status/2013/en/. is a driver with a high school education background. 8. Sarimawar D, et al. Gambaran Kecelakaan Lalu Lintas Di Indonesia Tahun 2010-2014. Jurnal 6. The most frequent traffic accidents based on the Ekologi Kesehatan. 2016;15(1):30-42. accident impact criteria from 2012 to 2016 caused many 9. Rifal A D. Faktor Risiko Yang Berhubungan dengan injuries. Kecelakaan Lalu Lintas Pada Pengemudi BUS P.O Jember Indah. 2015. Available from http:// 7. The most frequent traffic accidents based on the repository.unej.ac.id/handle/123456789/73244. unsafe acts and conditions of traffic accidents from 2012 to 2016 are due to the human factor of unskilled drivers. 10. Haris I V. Kajian Daerah Rawan Kecelakaan Lalu Lintas di Jalan Kolektor Primer Wilayah Gresik Ethical Clearance: Ethical clearance was not Bagian Selatan Tahun 2012. 2013. Available from required hence was not obtained https://jurnalmahasiswa.unesa.ac.id/index.php/ swara-bhumi/article/view/3188. Source of Funding: Self funded 11. Wilandari Y, Sugito S, Silvia C.Analisis Kecelakaan Lalu Lintas Di Kota Semarang Menggunakan Conflict of Interest: NIL Model Log Linier. Media Statistika. 2016;9(1):51- References 61. 12. Simanungkalit H M T R, Aswad Y. Analisis Faktor 1. Direktorat Jenderal Perhubungan Darat. Laporan Penyebab Kecelakaan Lalu Lintas Di Ruas Jalan Akhir Pedoman Teknis Kampanye Program Sisingamangaraja Kota Medan. Jurnal Teknik Sipil Keselamatan. 2010. USU. 2014;3(2). Available from https://jurnal.usu. 2. Notoajmodjo, Soekidjo. Metodologi Penelitian ac.id/index.php/jts/article/view/7186/2997. Kesehatan. 2010. 13. Dewar R E, Olson P L. Human Factor in Traffic 3. Sugiyono. Metode Penelitian Kuantitatif, Kualitatif, Safety. Lawyers & Judges Publishing Company. R&D. 2012. 2007. 246 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13857 Type 2 Diabetes, Religious Beliefs and Psychological Interventions
Charity N. Onyishi1,2 1Postdoctoral Research Fellow, Department of Educational Psychology, University of Johannesburg, South-Africa, 2Lecturer, Department of Educational Foundations, University of Nigeria, Nsukka,Nigeria. ORCID 0000-0003- 4047-7850
Abstract This paper is a review regarding the relationship among Type 2 diabetes (T2D), religious beliefs and psychological interventions. Specifically, the paper x-rayed the prevalent state of diabetes, followed by the role of religious beliefs and psychological interventions in the management of the chronic disease for improved health care, social support, protective health behaviours, stress reduction, positive coping skills, psychological adaptation, psychosocial functioning, greater optimism, self-esteem, life satisfaction and treatment of depression and anxiety in people with type 2 diabetes. Overall, from the reviewed literature, religious beliefs and psychological interventions seem to be common coping mechanisms available to T2D patients where formal coping resources are not available.
Keywords: Diabetes, Type 2 diabetes, religion, religious belief, psychological interventions.
Introduction No studies examine the perspectives from religious education specialists about how religious beliefs in Diabetes mellitus (DM) is among the non union with psychological interventions can impact on communicable diseases1 typified by prolonged patience self-care, copping and management response hyperglycemia2, 3due to metabolic disorder2 deficiencies to diabetes.7,8 Additionally, patients’ religious belief in insulin secretion and/or action4. DM is emerging as and psychological interventions are common coping a major health problem in Africa1 with type 2 diabetes mechanisms employed where formal coping resources (T2D) being the most predominant2. The prevalence are not available like in Nigeria. Hence, this paper of type 2 diabetes is fast increasing. Improving T2D is aimed at reviewing the impact of T2D, the role of outcomes greatly depends on the patient’s motivation religious beliefs in T2D and the possible psychological for self-care like medication compliance, glucose intervention associated with the T2D. monitoring and modification of one’s lifestyle5. Previous studies have investigated the role of some of these Diabetes Prevalence diabetes self-management motivators such as support groups, education, anxiety, and family.6 Nevertheless, Previous research studies have testified to the religious belief and psychological intervention, even increasing rate of type 2 diabetes prevalence over 9,10 though identified motivators and relevant in T2D self- recent decades. According to NCD Risk Factor 11 management and care have gained the required attention Collaboration , the World Health Organization (WHO) in research.4 A good number of research studies have estimate carried out in 1980 indicates that 108 million been conducted on religious belief and psychological people living were with diabetes and this number interventions, but only a few looked at how religious doubled in 2014 estimates. The International Diabetes belief and psychological interventions influence Federation (IDF) also estimated the global prevalence 12 13 predominant chronic diseases, like diabetes especially to be 151 million in 2000 , 194 million in 2003 , 246 14 15 T2D. Existing literature on diabetes, religious beliefs million in 2006 , 285 million in 2009 , 366 million in 16 17 18 and psychological interventions are insignificant. 2011 , 382 million in 2013 and 415 million in 2015 . Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 247
Each estimate was based on the latest data available. This diabetes outcomes.35,30 Therefore, it is paramount that paper provides estimates of the worldwide and regional healthcare experts be acquainted with the role which impact of diabetes for 2017 and 2045, based on the most religion plays in the lives of diabetic patients and should recent epidemiological data. In Africa, the projected consider some religious factors in their development occurrence is between 1% to 7% in sub-Saharan Africa.19 health care programs.38 Presently, in sub-Saharan Africa about 20 million According to39 one’s religious practices, belief, people are estimated to have diabetes, and the amount is activates and feeling of spiritual cohesion with nature predicted to reach 41.4 million or 109.1% by 2035.20 In determines the person’s quality of life, how to cope sub‑Saharan Africa, Nigeria has the highest number of with a chronic disease, depressive symptomatology and people with T2D with an estimated 3.9 million people21 stress. Evidence from40 shows that African-American and the major cause of morbidity and mortality.22,23 In patients use religion and spirituality as a coping strategy Nigeria, the prevalence of T2D has been high and still for diabetes management and to change unhealthy be increasing, with the country widely reported as having haviors. In Nigeria, Christianity and Islam are the most Africa’s highest burden of diabetes.24 Additionally, the practised religion with Christianity dominant in the south 2013 IDF global study, reported a prevalence estimate of while Islam is practised in the north. Since Christians 5% for Nigeria, accounting for 3.9 million cases among and Muslims are the major religions in Nigeria, health persons aged 20–79 years.25 High prevalence of T2D practices are based on both beliefs. It, therefore, means diabetes and high mortality observed in patients with that patients’ self-management of T2D will be inspired by diabetes consequent and poor control result in huge costs their religious beliefs. For instance, within the Christian in managing diabetes in Nigeria, sub-Saharan Africa and folds, an untreated T2D can lead to death which can the rest of the developing world. result due to the person’s religious belief and strong faith Religious Beliefs and T2D Self-Management in God that only God can cure T2D and not medicines. Among the Muslims, fasting is part of their religious Before now, a lot of studies have investigated beliefs, and this sometimes affects their decisions about the role patient’s religious belief plays in the control insulin therapy because of potential interference with of the impact of T2D.26-30 These studies have shown their religious obligations.41 Furthermore, a study by42 that there are a lot of promising pathways connecting publicized that 37% of patients using insulin and 20% of disease management30 and religious beliefs affecting patients using oral anti-diabetic medicines altered their health outcomes.31-33 Religion is a well-structured and doses during Ramadan. In Nigeria, the leaders of the communal belief system of reverence to God, expressed churches, mosques and other religious communities play through external rituals of worship34 and promotes the influential roles in determining the behaviours, opinions, relationship of the individual with God35. Religious and attitudes of their members. Researchers have belief, on the other hand, is the fundamental belief system shown that religion can assist patients in the adoption that could influence our ideas, values in life and ways of of protective health behaviors43, social support44, stress living.36 Thus, physicians must consider religious issues reduction, positive coping skills45,46, psychological during health care management37. Subsequently, recent adaptation47-49, psychosocial functioning50, greater studies have revealed the significant roles religious optimism, self-esteem, and life satisfaction.51,52 leaders play in promoting health and well-being of members38, such that through their advice and guidance Psychological Intervention can assist members in promoting healthy lifestyles, Studies have shown that problems associated with healthy behaviours and the development of health mental health among diabetes patients can be treated promotion programs39. They, therefore, can support T2D using psychological interventions.53-56 Most of the patients to deal with the chronic infirmities associated research conducted focused on depressive symptoms of with T2D.38,30 Also, such religious strategies as reading diabetes patients and the findings advocate that the effect of the Bible/spiritual books, faith in God, seeking of psychotherapy on glycaemic control and depressive help, prayers and social support by members of the symptoms is greater when compared with antidepressant congregations and their religious beliefs may improve 248 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 treatment, particularly when carried out jointly with self- and psychological interventions are common coping management education. Psychological interventions, mechanisms that can be used by patients, physicians and counselling, and psychotherapy, are common terms others stakeholders where formal coping resources are often used interchangeably and people referred for not available like in Nigeria to self-manage the disease such interventions may receive different types of verbal for improved care and prevention. therapies such as supportive therapy, psychodynamic Ethical Clearance- Not required or psychoanalytic therapy, motivational interviewing, interpersonal therapy and behavioural therapy. Supportive Source of Funding- Self therapy can be used to increase T2D patient’s self-esteem and adaptive skills and ascertains unhelpful behaviours Conflict of Interest – Nil by exploring the person’s interpersonal patterns. On the other hand, psychodynamic (or psychoanalytic) therapy References uses past experiences to understand current behaviour. 1. Mbanya JC, Bonicci F, Nagan K. 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Christine Handayani Siburian1, Ikhsanuddin A. Harahap2, Ridha Dharmajaya3 1Master Student, Faculty of Nursing, Universitas Sumatera Utara, Indonesia, 2 Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Indonesia, 3Lecturer, Faculty of Medicine, Universitas Sumatera Utara, Indonesia
Abstract Background: Cancer is a growing disease and a leading cause of death globally. Cancer can be treated with chemotherapy treatment which causes side effects like symptom distress. Symptom distress can be overcome by non-pharmacological, one of which is flexibility exercise.
Object: to identify effect of flexibility exercise on symptom distress in cancer patients undergoing chemotherapy.
Methods: The study design used a quasi-experimental design with an equivalent control group. There were 40 respondents of cancer patients who are undergoing chemotherapy which were divided into two groups, 20 intervention, and 20 control groups. The sampling technique was consecutive sampling. The data were collected by the Symptom Distress Scale. The data were analyzed by a paired t-test in the intervention group before and after the intervention and control group.
Results: The results obtained were differences in symptoms distress in the intervention group after flexibility exercise (t=13.24, p=0.00). The study was also analyzed by an independent t-test showing that there were differences in symptoms distress between the intervention and the control group of cancer patients undergoing chemotherapy (t=-2.42, p=0.02).
Conclusion: The flexibility exercise can be a non-pharmacological measure to help reduce symptoms of cancer patients undergoing chemotherapy.
Keywords: Cancer patient, Flexibility exercise, Symptom distress
Introduction Cancer in Indonesia in 2013 amounted to 347,792 people. Java, especially the Central and Eastern parts, Cancer is a condition that disrupts the process of is an area with most people with cancer in Indonesia, growth and spread of cells that can cause death. In 2018, namely ±68,638 and ±61,230 people. Cancer cases in cancer is the second leading cause of global death which North Sumatra province reached 1.0% (13,391 people) has reached 9.6 million deaths. Lung, prostate, colorectal, of the total number of cancer patients in Indonesia.(2) stomach and liver cancers are the most common types of cancer in men, and cancers often affecting women are The treatment used for cancer patients is breast, colorectal, lung, cervical and thyroid cancers.(1) chemotherapy. Bruce said that chemotherapy is a treatment given in several cycles whose function is to kill cancer cells or slow their growth.(3) Chan and Corresponding author Ismail said that the administration of chemotherapy Christine Handayani Siburian: will cause side effects.(4) According to Choi et al. Said e-mail: [email protected] that chemotherapy can negatively affect body image, Jalan Prof. Maas No.03, Kampus USU, Medan 20155, psychosocial well-being, and depression of breast cancer Sumatera Utara, Indonesia patients.(5) Besides, cancer patients will also experience 252 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
insomnia.(6) These side effects are part of symptoms of intervention and 20 control groups) cancer patients distress. undergoing chemotherapy at Haji Adam Malik General Hospital Medan. Symptoms distress occurs due to a diagnosis of cancer, increased side effects of treatment, and severity Inclusion criteria namely: cancer patients who of symptoms.(7) Symptom distress arises by looking after 24 hours of undergoing chemotherapy by the at several symptoms namely nausea (frequency and intravenous route, chemotherapy is performed at least intensity), appetite, insomnia, pain (frequency and in the second cycle, do not experience musculoskeletal intensity), fatigue, bowel movements, concentration, disorders, do not suffer from heart disease, bone cancer, appearance, breathing, sight, and cough.(8) Pettersson et and do not experience cancer that have been metastases al. showed that cancer patients undergoing chemotherapy to the bone, do not experience anemia, leukopenia, and will experience symptoms distress that are tingling in the thrombocytopenia, respiratory rate, heart rate, body hands/feet (64%), lack of energy (62%), feeling sleepy temperature and blood pressure within normal limits, do (49%), and nausea (45%). Symptom distress can be not vomit within the previous 24 to 36 hours and have reduced by physical exercise.(9) full awareness, Cooperative.
According to Paul, that exercise that is applied to Measurement of symptoms distress using the patients must be adapted to the physical condition of Symptom Distress Scale (SDS) questionnaire. This the patient and he recommends the type of exercise for measuring instrument has been validated by 3 experts, cancer patients undergoing chemotherapy is flexibility CVI=0.99, internal consistency test 0.916, interrater exercise. Paul said flexibility exercise is an exercise reliability test 0.67. Measuring instruments were used to to extend muscles and tendons that can increase measure symptoms before and after flexibility exercise. muscle tone and joint movement.(10) The Christie NHS The flexibility exercise intervention was carried out Foundation Trust explains that exercise flexibility is one in 3 sets which were carried out 5 times a week, for 20- exercise that if done regularly can overcome side effects 30 minutes, and carried out in 2 weeks in cancer patients of chemotherapy.(11) undergoing chemotherapy. The data were analyzed by Methods pair t-test in the intervention group before and after the intervention and control group and also analyzed by This research was quantitative research with a independent t-test. quasi-experimental with a pre-test post-test with a control group approach. This study was 40 people (20
Results Tabel 1. respondent characteristics
Intervention Group Control Group Variables n % n % Ages Early adult 2 10,00 1 5,00 Late adult 2 10,00 10 50,00 Early elderly 6 30,00 7 35,00 Late elderly 10 50,00 2 10,00 Mean ± SD 52,10 ± 8,99 46,10 ± 6,73 Min – Max 34 – 65 35 – 62 Gender Man 3 15,00 3 15,00 Women 17 85,00 17 85,00 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 253
Cont... Tabel 1. respondent characteristics
Educational Primary 1 5,00 7 35,00 Junior 3 15,00 7 35,00 Senior 11 55,00 4 20,00 College 5 25,00 2 10,00
Employment Unemployment/ housewives 11 55,00 6 30,00 Entrepreneur 3 15,00 5 25,00 Private employee 3 15,00 3 15,00 Civil officer 3 15,00 1 5,00 Farmer - - 5 25,00
Cancer types Breast 12 60,00 12 60,00 Ovarium 4 20,00 4 20,00 Nasofaring 2 10,00 2 10,00 30%Non-Hodgkin Lymphoma 2 10,00 2 10,00
Long suffered cancer Chronic 12 60,00 12 60,00 Acute 8 40,00 8 40,00
Chemotherapy cycles II 6 30,00 8 40,00 III 4 20,00 4 20,00 IV 5 25,00 4 20,00 V 3 15,00 1 5,00 VI 2 10,00 3 15,00
Table 1. shows that the majority of late elderly (50%), that the majority of late adult (50%), the majority gender the majority gender were women (85%), the majority were women (85%), the majority education were primary education were senior high school (55%), the majority (35%) and junior high school (35%), the majority respondents were unemployed/housewives (55%), the respondents were unemployed/housewives (30%), the majority of cancer were breast (60%), chronic cancer majority of cancer were breast (60%), chronic cancer was the suffering from the respondents (60%), and the was the suffering from the respondents (60%), and the chemotherapy cycle was undergone second cycle (30%). chemotherapy cycle was undergone second cycle (40%). Characteristics of control group based on age showed 254 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 2. distribution frequency of symptom distress
Intervention group Control group
Symptom Distress before after before after
n % n % n % n %
Mild 3 15 12 60 3 15 8 40
Moderate 6 30 8 40 5 25 8 40
Severe 11 55 - - 12 60 4 20
Mean ± SD 32,15 ± 7,28 22,40 ± 4,74 33,10 ± 6,80 26,40 ± 5,66
Min - Max 18 – 43 14 – 30 22 – 43 16 – 37
Table 2. shows that the intervention group before the flexibility exercise more than half the number of respondents (55%) experienced severe symptoms distress with an average score of 32.15 (SD = 7.28) and the control group also more than half the number of respondents (60% ) experienced severe symptoms distress with an average score of 33.10 (SD=6.80). After done flexibility exercise for 2 weeks, the symptom distress decreased, which is more than half the number of respondents (60%) experienced mild symptoms distress in the intervention group with an average score of 22.40 (SD=4.74) and the control group less than half experienced mild (40%) and moderate (40%) symptoms distress with an average total score of 26.40 (SD=5.66).
Table 3. symptom distress based on the items
Intervention group Control group Symptom Distress Scale before after before after
Nausea (frequency) Mean ± SD 2,75 ± 0,79 1,95 ± 0,69 2,65 ± 0,67 1,90 ± 0,72 Min – Max 1 – 4 1 – 3 2 – 4 1 – 3 Nausea (Intensity) Mean ± SD 2,20 ± 0,83 1,60 ± 0,68 2,30 ± 0,80 1,80 ± 0,62 Min – Max 1 – 4 1 – 3 1 – 4 1 – 3 Appetite Mean ± SD 2,85 ± 1,09 2,05 ± 0,89 2,95 ± 1,05 2,35 ± 0,93 Min – Max 1 – 5 1 – 4 1 – 5 1 – 4 Insomnia Mean ± SD 3,25 ± 1,25 2,25 ± 0,91 3,30 ± 1,03 2,80 ± 1,11 Min – Max 1 – 5 1 – 4 1 – 5 1 – 5 Pain (frequency) Mean ± SD 2,55 ± 0,76 1,80 ± 0,62 2,60 ± 0,94 2,00 ± 0,73 Min – Max 1 – 4 1 – 3 1 – 4 1 – 3 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 255
Cont... Table 3. symptom distress based on the items
Pain (Intensity) Mean ± SD 2,10 ± 0,72 1,40 ± 0,50 2,05 ± 0,61 1,75 ± 0,55 Min – Max 1 – 3 1 – 2 1 – 3 1 – 3 Fatigue Mean ± SD 2,50 ± 0,95 1,75 ± 0,71 2,85 ± 1,09 2,30 ± 0,92 Min – Max 1 – 4 1 – 3 1 – 5 1 – 4 Defecation Mean ± SD 2,45 ± 0,89 1,75 ± 0,72 2,55 ± 1,15 2,00 ± 0,92 Min – Max 1 – 4 1 – 3 1 – 4 1 – 3 Concentration Mean ± SD 2,15 ± 0,99 1,45 ± 0,69 2,50 ± 0,89 1,90 ± 0,79 Min – Max 1 – 4 1 – 3 1 – 4 1 – 3 Appearance Mean ± SD 2,80 ± 0,83 1,95 ± 0,69 2,65 ± 1,04 2,25 ± 1,07 Min – Max 1 – 4 1 – 3 1 – 4 1 – 4 Breathing Mean ± SD 1,65 ± 0,67 1,10 ± 0,31 1,95 ± 0,76 1,40 ± 0,50 Min – Max 1 – 3 1 – 2 1 – 3 1 – 2 View Mean ± SD 2,75 ± 1,02 1,90 ± 0,85 2,95 ± 0,89 2,45 ± 0,69 Min – Max 1 – 5 1 – 4 1 – 4 1 – 3 Cough Mean ± SD 2,15 ± 0,88 1,45 ± 0,51 1,80 ± 0,70 1,50 ± 0,61 Min – Max 1 – 4 1 – 2 1 – 3 1 – 3
Table 4. the difference in symptom distress before and after the flexibility exercise Intervention group Control group Variables t (sig) t (sig) Symptom Distress (total score) 13,24 (0,00) 7,39 (0,00) Nausea (frequency) 6,84 (0,00) 7,55 (0,00) Nausea (Intensity) 5,34 (0,00) 4,36 (0,00) Appetite 8,72 (0,00) 5,34 (0,00) Insomnia 6,89 (0,00) 4,36 (0,00) Pain (frequency) 7,55 (0,00) 5,34 (0,00) Pain (Intensity) 6,66 (0,00) 2,85 (0,01) Fatigue 7,55 (0,00) 4,82 (0,00) Defecation 6,66 (0,00) 4,82 (0,00) Concentration 6,66 (0,00) 4,49 (0,00) Appearance 7,77 (0,00) 3,56 (0,02) Breathing 4,82 (0,00) 4,82 (0,00) View 7,77 (0,00) 4,36 (0,00) Cough 4,77(0,00) 2,85 (0,01) 256 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 4. shows that the results of this study indicate that there were differences in symptom distress between before and after flexibility exercise in the intervention group (t=13.24, p=0.00) and the control group also found differences in symptom distress (t=7.39, p=0.00). The difference in symptoms distress based on the items can be seen in Table 4 below.
Table 5. differences in symptom distress in the intervention and control group
Variables T Sig
Symptom Distress (Total Score) -2,42 0,02
Nausea (frequency) 0,00 1,00
Nausea (Intensity) -0,98 0,34
Appetite -1,04 0,30
Insomnia -2,92 0,01
Pain (frequency) -0,94 0,35
Pain (Intensity) -2,10 0,04
Fatigue -2,11 0,04
Defecation -0,96 0,34
Concentration -2,08 0,04
Appearance -1,06 0,30
Breathing -2,28 0,03
View -2,25 0,03
Cough -0,28 0,78
Table 5. shows that The results found no differences that there was a difference in insomnia (t= -2.92, in symptoms distress between the intervention group p=0.01) after the flexibility exercise. The difference after the flexibility exercise and the control group of after the flexibility exercise intervention was a decrease cancer patients undergoing chemotherapy (t -2.42, in insomnia. According to Chuang et al. there was a p=0.02). Symptom distress based on the items shows difference between groups after regular exercise for 21 that there were some items that had differences between days in improving sleep quality (t=17.73, p <0.001).(12) the intervention groups after the flexibility exercise In addition to the relaxing effect, physical exercise can intervention and the control group of cancer patients increase the activity of the 5-HT system (serotonin) in undergoing chemotherapy, namely difficulty sleeping the cortex, hippocampus and raphe nuclei.(13) (t -2.92, p=0.01), pain intensity (t=2.10, p=0.04 0.04)), fatigue (t=-2.11, p=0.04), concentration (t = -2.08, p = Symptom distress based on pain intensity items 0.04)), respiration ( t = -2.28, p = 0.03), and views (t = showed that there were differences in pain intensity -2.25, p = 0.03). (t=-2.10, p=0.04) after the flexibility exercise was performed. The difference after the flexibility exercise Discussions intervention was that respondents feel a decrease in pain intensity. Pain felt by cancer patients undergoing Symptom distress based on insomnia items showed Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 257
chemotherapy can be influenced by several things, undergoing treatment.(21) namely the type of chemotherapy drug regimen given, Symptom distress based on breathing items appeared side effects arising from chemotherapy drugs such as that there were differences in breathing between groups pain from oral mucositis, headache, neuropathy, routes after the flexibility exercise action and the control group of chemotherapy (such as intraperitoneal chemotherapy (t=-2.28, p=0.03). The difference after the flexibility that can cause pain acute abdomen) and pain arising exercise intervention was the existence of breathing that from the development of the cancer itself.(14) Brad said returned to normal and reduced difficulty in breathing. that flexibility exercise has benefits for reducing pain Appropriate physical exercise can improve respiratory and increasing relaxation.(15) According to Banu said muscles and lung ventilation muscles so that the lungs that regular physical exercise can stimulate the body to can work properly, oxygen levels can increase in the produce endorphins which can reduce pain.(16) body, and the supply of oxygen to the tissues can be Symptom distress based on item fatigue shows that fulfilled.17 The results are following Jastrzębski et al. there was a difference in fatigue (t=-2.11, p=0.04) after that physical exercise performed in 2 months provides the exercise flexibility measures. The difference after the reduced dyspnea in lung cancer patients undergoing flexibility exercise intervention was that respondents felt chemotherapy (p=0.005).(22) a decrease in fatigue. Blood flow that binds with oxygen Symptom distress based on the item view shows into the tissue, which then occurs metabolism so that that there were differences in views (t=-2.25, p=0.03) energy is formed and the energy can reduce fatigue.(17) after doing flexibility exercise. The difference after Flexibility exercise can increase energy and can reduce the flexibility exercise intervention was a decrease in fatigue.(15) the view of concern or fear of the future. The view in Symptom distress based on the item concentration question is anxiety in cancer patients who are receiving showed that there were differences in concentration chemotherapy treatment. According to Bruce said between the groups after the flexibility exercise and the that flexibility exercise can improve mood and self- control group (t = -2.08, p=0.04). The difference after confidence of cancer patients who get treatment.(3) the flexibility exercise intervention was an increase This study is by the research of Chen et al. said that in the concentration of the respondents. Based on the physical exercise program for 12 weeks at home the qualitative study of Bolton and Isaacs describes in cancer patients receiving treatment showed an the experience of breast cancer women undergoing improvement in coping with their anxiety levels in the treatment who have difficulty remembering things and third month (p = 0.009) and sixth month (p = 0.006) the inability to stay focused on a task.(18) In addition than the group of patients with usual care.(23) Mehnert to providing relaxation, flexibility exercise also et al. also gave the same opinion that physical exercise affects increasing body circulation.(15) Increased blood carried out for 2 months 2 weeks influenced the level of circulation in the body causes oxygen to be circulated anxiety (p = 0.03) in breast cancer patients who received optimally to the body’s tissues, especially to the brain. chemotherapy treatment.(24) Maximum oxygen in the brain can improve the workings of the brain system and increase concentration power. Conclusions (16) The results of this study are following Loprinzi and Tere were differences in distress symptom between Kane, which is that training done with moderate intensity before and after the flexibility exercise intervention in can increase the cognitive concentration of patients the intervention group of cancer patients undergoing (19) (mean=145.1, SD=26.9, p=0.004). Mustian et al. also chemotherapy, there were differences in symptom said that moderate-intensity exercise can improve the distress between the intervention groups after it was ability of concentration in cancer patients undergoing performed flexibility exercise intervention and a control (20) treatment. Also, the opinion of other researchers group of cancer patients undergoing chemotherapy. This said that exercise that was carried out regularly for 24 study recommends that flexibility exercise can be a non- weeks significantly (r=0.45, p=0.001) could influence pharmacological measure to help reduce symptoms of the increase in the concentration of cancer patients cancer patients undergoing chemotherapy. 258 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Conflict of Interest: There was not a conflict of S. Symptom prevalence, frequency, severity, and interest in this article. distress during chemotherapy for patients with colorectal cancer. Supportive Care in Cancer. 2013; Source of Funding: No funding this is a study 22(5): 1171–1179. Ethical Consideration: This study was approved 10. Paul RJ. Exercise promotion during chemotherapy by the Commission of Health Research Ethics of the treatment: recommendations for the Australian oncology nurse. Australian Journal of Cancer Faculty of Nursing University of Sumatera Utara Nursing. 2017; 18(1): 15–19. (Approval No. 1709/III/SP/2019). 11. The Christie NHS Foundation Trust. A guide for References exercising during and after treatment for cancer. 2014;1–18. 1. World Health Organization. Cancer. 2018 [Internet]; [Cited 2019 June 15]. Available from: 12. Chuang TY, Yeh ML, Chung YC. A nurse facilitated https://www.who.int/news-room/fact-sheets/detail/ mind-body interactive exercise (Chan-Chuang cancer. qigong) improves the health status of non-Hodgkin lymphoma patients receiving chemotherapy: 2. Ministry of health of Republic of Indonesia. Stop Randomised controlled trial. International Journal Kanker, Situasi Penyakit kanker. Pusat Data dan of Nursing Studies. 2017;69: 25–33. Informasi Kementerian Kesehatan RI, 2; 2015 [cited 2019 June 27]. Available from: https:// 13. Pietrelli A, Matković L, Vacotto M, Lopez-Costa JJ, pusdatin.kemkes.go.id/article/view/15090700004/ Basso N, Brusco A. Aerobic exercise upregulates situasi-penyakit-kanker.html. the BDNF-Serotonin systems and improves the cognitive function in rats. Neurobiology of 3. Bruce J. Exercise for People Living with Cancer. Learning and Memory. 2018; 155: 528–542. Cancer Council Australia. 2016; 5: 14-14 1p. 14. Portenoy RK, Ahmed E. Cancer Pain Syndromes. 4. Chan H, Ismail S. Side Effects of Chemotherapy Hematology/Oncology Clinics of North America. among Cancer Patients in a Malaysian General 2018; 32(3): 371–386. Hospital : Experiences, Perceptions and Informational Needs from Clinical Pharmacists. 15. Brad W. Ultimate Guide To Stretching and 2014; 15: 5305–5309. Flexibility (3rd Editio). Injury Fix and the Stretching InstituteTM. 2011. 5. Choi EK, Kim IR, Chang O, Kang D, Nam SJ, Lee JE, Lee SK, Im YH, Park YH, Yang JH, 16. Banu SA. Peran Olahraga Sebagai Sumber Cho J. Impact of chemotherapy-induced alopecia Kekuatan Menghadapi Penyakit Kanker. Medikora. distress on body image, psychosocial well-being, 2010; 4: 31–40. and depression in breast cancer patients. Psycho- 17. Lismadiana L. Peranan Olahraga terhadap Oncology. 2014;23(10): 1103–1110. Kapasitas Kardiorespirasi. JORPRES (Jurnal 6. Sanford SD, Wagner LI, Beaumont JL, Butt Olahraga Prestasi). 2012; 53(9): 108–122. Z, Sweet JJ, Cella D. Longitudinal prospective 18. Bolton G, Isaacs A. Women’s experiences of assessment of sleep quality: Before, during, and cancer-related cognitive impairment, its impact after adjuvant chemotherapy for breast cancer. on daily life and care received for it following Supportive Care in Cancer. 2013; 21(4): 959–967. treatment for breast cancer. Psychology, Health and 7. Omran S, Saeed AMA, Simpson J. Symptom Medicine. 2018; 23(10): 1261–1274. distress of Jordanian patients with cancer receiving 19. Loprinzi PD, Kane CJ. Exercise and cognitive chemotherapy. International Journal of Nursing function: A randomized controlled trial examining Practice. 2012; 18(2): 125–132. acute exercise and free-living physical activity and 8. Stapleton SJ, Holden J, Epstein J, Wilkie DJ. A sedentary effects. Mayo Clinic Proceedings. 2015; systematic review of the symptom distress scale 90(4): 450–460. in advanced cancer studies. Cancer Nursing. 2016; 20. Mustian KM, Sprod LK, Janelsins M, Peppone LJ, 39(4): E9–E23. Mohile S. Exercise Recommendations for Cancer- 9. Pettersson G, Berterö C, Unosson M, Börjeson Related Fatigue, Cognitive Impairment, Sleep Problems, Depression, Pain, Anxiety, and Physical Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 259
Dysfunction—A Review. Oncology & Hematology 23. Chen HM, Tsai CM, Wu YC, Lin KC, Lin CC. Review (US). 2012; 08(02): 81. Randomised controlled trial on the effectiveness 21. Knobf MT, Thompson AS, Fennie K, Erdos D. The of home-based walking exercise on anxiety, effect of a community-based exercise intervention depression and cancer-related symptoms in patients on symptoms and quality of Life. Cancer Nursing. with lung cancer. British Journal of Cancer, 2015; 2014; 37(2): 43–50. 112(3): 438–445. 22. Jastrzębski D, Maksymiak M, Kostorz S, Bezubka 24. Mehnert A, Veers S, Howaldt D, Braumann B, Osmanska I, Młynczak T, Rutkowska A, Baczek KM, Koch U, Schulz KH. Effects of a physical Z, Ziora D, Kozielski J. Pulmonary rehabilitation in exercise rehabilitation group program on anxiety, advanced lung cancer patients during chemotherapy. depression, body image, and health-related quality In Respiratory Health. Springer. 2015; 6: 57–66. of life among breast cancer patients. Onkologie. 2011; 34(5): 248–253. 260 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13859 A Qualitative Study: The Phenomena of Child Marriage in Urban Areas of Surabaya City Reviewed from Comprehension of Reproductive Health
Dessy Fitriana1, Rize Budi Amalia1, Nur Ainy Fardana2 1Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia,2Faculty of Psychology, Universitas Airlangga, Surabaya, East Java, Indonesia
Abstract Child marriage under 18 years old has become a global health and social problem long-term risk towards adolescent girls. The fact shows that information of reproduction health has not been able to empower bride to prepare themselves about the plan of healthy family and quality pregnancy. This study aims to explore the phenomenon of child marriage in term of comprehension the reproductive health the bride the city of Surabaya.
The study uses exploratory phenomenology paradigm approach with in-depth interview to 7 brides-to-be who were getting married. The data was obtained from three offices of The Office of Religious Affairs in the city of Surabaya with a high prevalence of child marriage before 18 years old.
The risk factors for the child marriage in the city of Surabaya are influenced by internal factors and external factors. The low of knowledge, The lack of caring and low role of participants in self-empowering about reproductive health would be impact to unplanned pregnancy and family life planning to.
Midwives as one of premarital health care providers are have to provide solutions that were promotive and comprehension of reproductive healths including planning for pregnancy and healties of family.
Keywords: Brides, Child Marriage, Reproductive Health, Women Empowerment
Introcudtion The long-term effects of child marriage are very harmful. Young girls have a risk due to forced marriages, Child marriage is a marriage that happens at the age sexual intercourse at an early age, pregnancy at a young of children, which is a girl or boy lives with a spouse and age, and sexually transmitted infections6. Adolescence gets married before the age of 1818.Data from the United in girls, which should be a time for getting physical Nations Children’s Fund (UNICEF) showed that the development, by child marriage they often get negative prevalence of marriage before the age of 18 was 21% in impact on their health, emotional and social status21. worldwide. It was estimated that more than 150 million girls will marry before the age of 18 by 2030. Indonesia Three categories which can influence the child is still included to one of the 11 countries in the ASEAN marriage occurrence, such as family structure, low region that are vulnerable to high maternal and infant autonomy in decision making, and response to needs12. mortality rates due to child marriage21. The high number of child marriages indicates that reproductive health problems for women, including planning a safe pregnancy and childbirth by health Corresponding author: workers, should be a common concern, because that Dessy Fitriana will have a wide impact on various aspects of life in the Email: [email protected] long term10. Based on this, in order to create healthy Jl. Mayjen Prof. Dr. Moestopo 47 Surabaya generations and offspring and mothers to give birth Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 261 safely, so every couple needs a planning for a healthy registered at the local KUA. The participants were taken pregnancy and family through the Catin Program. by using a purposive technique approach. A total of 7 prospective brides as key participants will get married. Currently, child marriage seems to be a trend even Data was collected by using in-depth interviews then in urban areas. This is an anomaly when the access it was processed manually and analyzed using 6 (six) to information is easy to get, but the facts in the field stages of thematic analysis namely 1) scanning, 2) are still lacking in information and understanding of building general sense, 3) coding data, 4) describing the reproductive health so that many parties, especially the settings, people, categories, themes to be analyzed, 5) prospective bride, are helpless. Therefore, this study write a complete description and themes, 6) interpret and purposed to explore the phenomenon of child marriage interpret the data. in terms of understanding about the reproductive health of the bride and groom in Surabaya City. Results and Discussion Method The participants who met the inclusion criteria and were willing to be interviewed as many as 7 participants. This study was a qualitative descriptive with a Premarital pregnancy was experienced by P1 and P4 phenomenological approach. This study focused on experienced and both were dropped out of their school. the prospective bride in Surabaya City. Participants P1 and P4 dropped out of school because she was in this study were prospective brides who registered influenced by friends outside of school. Based on the at the Office of Religious Affairs (KUA) which had results of in-depth interviews, P4 admitted to having a been determined, according to the inclusion criteria, personality that is selfish, naughty, stubborn and married including they were <18 years old, never married before, because she was already pregnant concluded Table 1.
Table 1. Characteristics of Participants
Participant Age Education Occupation Tribe Pregnant
16years Drop out 1 No Jawa Yes 7month Senior High School 17 years Drop out 2 Yes Jawa No 1month Senior High School 17years Drop out 3 No Madura No 1month Senior High School 17years Drop out 4 No Jawa Yes 1month Junior High School 17years 5 Senior high School No Madura No 7month 16years Drop out Elementary 6 No Madura No 10month School 17years 7 Elementary School No Madura No 8month
Source Data: primary data processed
In contrast to P4, P5 was born from a family with a high economic status. Even though they have finished high school, P5 got married at the age of a child due to coercion from parents or better known as matchmaking. 262 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
“I was not... I had an arranged marriage, not once. to equip themselves with beneficial knowledge about Three times, or four times. Hmmm .. I better be an optimal healthy family planning. Unplanned pregnancy ordinary person like my friend. It was said that I was is one of immature family planning forms. This causes capable but not, or difficult but not, I should not have a long-term risk to health. Participants with premarital an arranged marriage like this. I kept being matched, oh pregnancy did not really understand how they should my ... Madurese said it was Kerre ateh, I was afraid of maintain their pregnancy and had not prepared getting hurt .. Yes that’s my fiancé .. “(P5) themselves to become a mother.
Due to repeated matchmaking, P5 admited that Another reason to marry at the age of children is she often visited nightclubs as an outlet when she had the awareness to get married. The Madurese participant problems. who married at the age of <18 years old argued that if a woman had reached a certain age but had not yet “Not with me. I Only have been to ... Discotheque, married, she would be called an old maid and would be I did not drink (alcohol). I just Eliminated my dizziness, the subject of ridicule from the surrounding community. I was pressured by my parents because of that matchmaking. I was really depressed..”(P5) As for the marriage that happened to the participants, it is considered as a natural event and descendant of the Meanwhile, the third reason that underlies the ancestral ancestors. Another reason to marry at the age of participants getting married at the age of children is children is the awareness to get married. These matters because of their awareness or desire from themselves, become fundamental when it is carefully understood that such as P2, as a singer who has dropped out of school marrying off a child at <18 years of age will result in a because she claims to be lazy, then decides to get married pregnancy with multiple risks15. in order to avoid adultery. As a result, as a prospective bride, the participants “Um ... I don’t want ... want to make less ... whats did not fully understand the essence of marriage and that mean ... don’t want to be like that ... keep away from reproductive health that will be faced throughout their adultery ... that’s adultery. I just afraid to do adultery life cycle. like that in next time. So that the adultery would not be happened , and would not embarrase my family. “ (P2). Risk Factors for Child Marriage
The Phenomenon Process of Child Marriage in Marriage at the age of children is used as the solution terms of Understanding the Reproductive Health of chosen by parents to solve problems. Marriage is a way Prospective Bride out of premarital pregnancy17. And also used as the best choice15. However, this attitude is still pros and cons in Marriage in children under <18 years old is the community. influenced by internal factors and external factors9. Where these factors are also related to individual The results of this study indicate that child marriage health behavior, especially to the reproductive health is also influenced by personality. Participants with risky of the bride and groom. Some decision making before behavior tended to have a higher risk of practicing marriage is influenced by intervention from parents, child marriage by engaging in premarital sex. This is in another reason for child marriage is forced marriage accordance with previous research, that adolescents with or often known as matchmaking. So that the autonomy bad attitudes have 2.129 times the risk of engaging in of participants to empower themselves as future brides premarital sexual behavior than adolescents with good is low in determining their reproductive rights and attitudes20. Based on this description, parents should functions. provide proper care to their children so that they are able to form children with good personalities. Lack of information regarding reproductive health is anomalous or deviates from facts. Supposedly, with The second reason was the coercion of parents. P5 today’s sophistication of technology and the abundant and P6 experienced forced marriage. Cases of child amount of information, participants should be able marriage from Indonesia and Bangladesh, there are at Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 263
least 2 girls every second who are victims of forced of antiseptic fluids, but participants think this is due to marriages3. Some women with an average age of 15 in too much activity or fatigue. Indramayu indicated that a woman with a low economic The STD that participants knew about was HIV. 14. However, it contradicts the results of this study Although the comparison of the results of the 2012 because the intervention of child marriage carried out by IDHS with the 2007 IDHS which showed an increase in parents occurs in participants with sufficient and even the proportion of young girls who received information high socioeconomic status. about the reproductive system (8.6%)5. In fact, this The decision to marry at the age of the child is knowledge participants’ perceptions are still attached also influenced by the level of education of the parents to HIV transmission through the use of used eating and such as the participant’s father and mother. Lack of drinking utensils, touching or shaking hands. The lack information about reproductive health affects attitude of accurate information results in incorrect knowledge. in decisions making2.This study found that there were And the low level of education taken has resulted in less participants’ powerlessness in determining individual recent information held by participants. rights, including rights related to reproductive health There was No Healthy Pregnancy and Family that existed in them. Planning In socio-cultural terms, the habit of marrying in Planning and preparation for pregnancy are essential the family is a reflection. Cause of marriage too early is for the bride and groom to get married in building a because there is a cultural influence1. In local culture, it household. However, not all participants understand is believed that if girls do not get married soon, it will the meaning of planning. In According research by embarrass the family19. Girls who believe in culture Godha et al., (2013) that child marriage is significantly have 3,939 times the risk of marrying prematurely15. associated with a history of repeated labor at a close The third reason in this research is awareness. distance, unwanted pregnancy. Child marriage in India They married because of their own wishes 15. This desire leads to poorly controlled fertility16. More than 50% of does not automatically present itself. Of course, there pregnancies are not planned properly13. As happened to are several triggering factors that underlie P2, P3 and P4, who had premarital pregnancy, so that during her P7 having child marriages. In addition, participants also pregnancy she did not consume vitamins for pregnant found verbal and physical violence8. Lack of parental women. Consuming micronutrient vitamins in pregnant attention and affection often triggers adolescents to have women is very important. Therefore, the 1000 HPK premarital sex9. The partiacral system in the family program is expected to optimize the golden period for plays a major role in how to educate a child4. Which is babies for 0-24 months8. related to authoritarian parenting techniques applied by The follow-up in terms of self-empowerment, such the significant other. as the selection of contraceptives, the care of children Low Reproductive Health Knowledge who will be born will still rely on parents. The reason of inexperience and feeling still “I’m still a children”. Participants in this study did not want to Respondents intend to postpone their marriage but there mention their reproductive organs because they were are several determining factors such as family structure, embarrassed, they were not used to it and considered it autonomy low in decision making10. Children who as a sin and taboo to talk about it. Interventions carried receive care from mothers who have a history of being out by parents were not only substantive in the form of married at the age of children are feared to get wrong marriage, but also related to reproductive health1. care or neglect due to not being skilled in caring for 6 This study funding the fact is that participants not children . understanding, let alone to the stage of application in Previous research results indicate that there is reality.The problem of vaginal discharge that is often a relationship between internal and external factors experienced by participants is due to the continuous use on premarital sexual behavior17. The attitude of 264 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
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Faisal A. Barwais1 Assistant Professor in Exercise Physiology, Department of Physical Education, Faculty of Education, Umm Al- Qura University, Makkah, Saudi Arabia
Abstract Background: Whereas being physically active has well-documented benefits, physical inactivity causes major non-communicable diseases. This study assessed physical activity levels among female undergraduate students at Umm Al-Qura University (UQU) in Saudi Arabia.
Methods: This cross-sectional study was conducted during UQU’s first semester, spanning September to December 2019, and involved 516 female undergraduate students aged 18 to 27 years (mean age ± SD: 22.22 ± 1.8 years). The participants were administered the online version of the International Physical Activity Questionnaire.
Results: Among the participants, 322 (62%) had a total physical activity of 236.6 ± 141.3 MET (metabolic equivalent of task) minutes/week, indicating engagement in light-intensity physical activity; 184 (35.7%) had 2997.0 ± 613.3 MET minutes of activity per week, equivalent to moderate-intensity physical activity; and 10 of the participants registered 3193.7 ± 218.1 MET minutes of activity per week, pointing to vigorous physical engagement.
Conclusion: The female undergraduate students exhibited low rates of physical activity. Understanding these findings may increase awareness of implications for the essential development of government initiatives, especially Saudi Arabia’s Quality of Life Program 2030, which is aimed at increasing physical activity levels in all ages.
Keywords: female university students, International Physical Activity Questionnaire, physical activity, subjective assessment, metabolic equivalent of task
Introduction physical activity is well-known to engender benefits, physical inactivity causes an estimated 3.2 million In recent years, chronic diseases, such as deaths worldwide,7 making it one of the five main health hypertension, coronary heart disease, and diabetes, have threats in many countries.8 become primary causes of morbidity and mortality in 1,2 most parts of the world. This phenomenon resulted In the Kingdom of Saudi Arabia (KSA), recent largely from urbanization-related reductions in people’s economic growth has also been accompanied with 3 physical activity, which is defined by the World Health chronic disease problems related to physical inactivity, Organization (WHO) as “any bodily movement produced diet, and other behavioral lifestyle changes associated 4 by skeletal muscles that require energy expenditure.” with affluence.9 These behaviors, together with the Several of the latest studies have shown a positive increased use of technology and the changing patterns association between engagement in moderate-intensity of transportation, can lead to physical inactivity and physical activity for at least 30 minutes every day and increased sedentary time.9 This progressively sedentary a greater than 50% reduction in the risk of developing lifestyle occurs across all domains, particularly given the the aforementioned conditions as well as a 20% to 30% increasing popularity of computer usage, work-related reduction in the risk of premature mortality.5, 6 Whereas Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 267
sitting time, and video game playing.10 The WHO to 25 minutes to complete). The questionnaire consisted recommends that adults aged 18 to 64 years participate of three sections: a section on general characteristics, in either at least 150 minutes of moderate-intensity including age, height, and weight; one focusing on social aerobic physical activity, at least 75 minutes of vigorous status and educational level; and a section concentrating aerobic physical activity, or an equivalent combination on physical activity levels. of both throughout a week to improve cardiorespiratory Physical activity was assessed using the short form of and muscular fitness, enhance bone health, and reduce the Arabic version of the International Physical Activity the risk of chronic disease development.11 Questionnaire (IPAQ, available at www.ipaq.ki.se). The A population-based, cross-sectional study in the participants were required to report the frequencies (days KSA showed a low prevalence of physical activity as well as hours and minutes per week) and ongoing (men = 6.1%, women = 1.9%),12 with 60% of the levels of intensity (light, moderate, and vigorous) with Saudi adult population considered physically inactive; which they engaged in physical activity during the last this percentage is the highest among Gulf Cooperation seven days. The metabolic equivalent of task (MET) Countries.13 In terms of gender, previous nationwide method was used in the IPAQ scoring, in which three studies estimated that physical inactivity ranges between levels of intensity were assigned to MET estimates 44.5% to 66.6% and 72.9% to 78.1% for males and before the weekly total physical activity (MET minutes/ females, respectively.9 Studies likewise indicated that week) of the students was calculated. According to this 84% of students who remain physically active during protocol, then, total physical activity was classified into their university years are likely to establish habitual light-intensity physical activity (less than 600 MET physical activity throughout their lifetimes.14 By minutes/week), moderate-intensity physical activity contrast, of students who are physically inactive during (≥600 to <3000 MET minutes/week), and vigorous this period, 80% carry on with their sedentary habits physical activity (≥3000 MET minutes/week). after graduating from university.14 The participants consisted of only female With consideration for the above-mentioned issues, undergraduate students at UQU and those who followed assessing the physical activity of universities students the IPAQ guidelines. The study excluded post-graduate using subjective or objective measures may enable an students, and students who returned incomplete IPAQ accurate estimation of this age group’s health status and or whose questionnaires had missing values. Data were subsequently provide evidence that can inform changes entered into Google Forms before being transferred in lifestyle policy and culture. Such data can also foster into Microsoft Excel sheets by an independent research the development of strategies that can help them make assistant, after which the data were reviewed and physical activity part of their daily lives. Thus, the analyzed using the Statistical Package for the Social objective of this study was to assess the physical activity Sciences for Windows (version 26.0, IBM SPSS Inc., levels of female undergraduate students at Umm Al- Chicago, IL). Results were expressed in descriptive and Qura University (UQU) in the KSA. frequency statistics (means, standard deviations [SDs], and percentages) for categorical variables. Materials and Methods Results Undergraduate female students at UQU (n = 516) with ages ranging from 18 to 27 years (mean age ± SD: Table 1 lists the descriptive statistics (means and 22.22 ± 1.8 years) were invited to participate in the study, SDs) regarding the participants. The study involved 516 which covered a semester running from September to female students aged 18 to 27 years (mean age ± SD: December 2019. A convenience sample was recruited 22.22 ± 1.8 years), among whom 55.2% belonged to through email invitations, and WhatsApp groups were the age group of 22 to 23 years. The Body Mass Indices created to provide an avenue where the students could (BMIs) of the participants ranged from 15.4 to 46 kg/m2, complete a short online questionnaire (approximately 15 with the mean BMI being 27.2 ± 5.2 kg/m2. 268 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 1: Participants’ demographic characteristics (n = 516)
Variables Minimum Maximum Mean ± SD
Age (years) 18 27 22.22 ± 1.8
Height (cm) 150 189 172.0 ± 8.4
Weight (kg) 48 128 10.2 ± 14.7
BMI (kg·m-2) 15.4 46.0 27.2± 5.2
On the basis of the BMI data, approximately 37.4% of the students were overweight, whereas 31.4% exhibited a normal weight. Obese participants accounted for 28.3% of the sample, and the remaining 2.9% were underweight (Table 2). With respect to social status, the majority of the participants (473 or 91.7%) were single at the time of the study, and 34 (6.6%) were married. In terms of educational levels, 459 (89%) participants had bachelor’s degrees, and 57 (11%) acquired diplomas.
Table 2: Body mass index category, social status, and educational level (n = 516)
Categorical variables Frequency n (%)
Body mass index category a
Underweight 15 (2.9%)
Normal weight 162 (31.4%)
Overweight 193 (37.4%)
Obese 146 (28.3%)
Social status
Single 473 (91.7%)
Married 34 (6.6%)
Other 9 (1.7%)
Educational level
Bachelor 459 (89%)
Diploma 57 (11%)
a BMI groups were defined using the WHO classification system being; underweight
< 18.5 kg/m2, normal ≥ 18.5–24.9 kg/m2, overweight ≥ 25–29.9 kg/m2, and obese ≥ 30 kg/m2.
The varying physical activity levels measured using the IPAQ are presented in Table 3. The descriptive statistics indicated that 322 (62%) participants had a total physical activity of 236.6 ± 141.3 MET minutes/week, categorizing the engagement of these individuals under light-intensity physical activity. Of the sample, 184 (35.7%) participants registered 2997.0 ± 613.3 MET minutes/week, corresponding to moderate-intensity physical activity, and 10 recorded 3193.7 ± 218.1 MET minutes/week, indicating involvement in vigorous physical activity. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 269
Table 3: Physical activity levels as reflected by MET minutes/week n( = 516)
Physical activity levels n (Mean ± SD)
Light-intensity physical activities 322 (236.6 ± 141.3)
Moderate-intensity physical activity 184 (2997.0 ± 613.3)
Vigorous-intensity physical activities 10 (3193.7 ± 218.1)
that female adolescents are relatively more inactive Discussion physically than males, with levels reaching 43% to 91% As previously stated, most of the participants versus 26% to 85%, respectively. were unmarried, had bachelor’s degrees, and had BMIs Given the well-documented full-health benefits that classified them under the overweight category. The of being physically active, individuals must involve BMIs ranged from 15.4 to 46 kg/m2, with the mean themselves in moderate to vigorous physical activities, BMI being 27.2 ± 5.2 kg/m2—a value higher than those such as jogging, bicycling, and swimming. The results observed in previous studies involving similar target of the current research and those of previous studies populations in the KSA.15–18 indicated high inactivity rates among female students, The results indicated that 62% of the participants driving researchers to focus on identifying the kinds engaged in light-intensity physical activity, thereby of physical activities that females choose to engage in failing to meet the physical activity recommendations and the perceived barriers to such engagement. Several of the WHO. This study is not the first to reveal a studies identified the following major reasons for prevalence of physical inactivity among female college inactivity among females: limited opportunities to engage students in the KSA, but it is distinguished from in moderate to vigorous physical activity; increasing previous work in that it emphasizes the importance of amounts of time spent on sedentary behaviors; lack of specifying the level of physical activity among such time, money, and support from family and friends; pain a sample. Similar results were derived by Desouky et when exercising; many lifestyle policies; cultural and al.19, who administered the long version of the IPAQ to civilization-related factors; and individual economic- female university students of the Health Colleges at Taif related reasons.9, 21 University in the KSA. The authors reported that many (61.7%) of the respondents were physically inactive. Conclusion Likewise, a recent study involving female college The results showed low rates of physical activity students at Taibah University in the KSA uncovered among female undergraduate students of UQU. Of the that more than half of the participants do not satisfy participants, 62% did not satisfy the WHO physical recommended levels of physical activity.16 Research on activity recommendations. Understanding these findings 831 females students at King Khalid University located may increase awareness of implications for the essential in the southwestern region of the KSA employed the development of government initiatives, especially Saudi short form Arabic IPAQ and found that 58.8% of the Arabia’s Quality of Life Program 2030, which is aimed participants are physically inactive.20 These findings at increasing physical activity levels in all ages. support the hypothesis that adolescents who cannot meet public health recommendations for physical engagement Acknowledgment: The author would like to thank among their age groups sustain a physically inactive the research participants for their involvement in the lifestyle as they grow older. Al-Hazzaa9 reviewed study. studies on inactivity prevalence and perceived barriers to Source of Funding: None active living among the Saudi population and discovered 270 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Conflict of Interest: None 10. Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, et al. Amount of time Ethical Clearance: This study was ethically spent in sedentary behaviors in the United States, approved by the ethics committee of Umm Al-Qura 2003-2004. Am J Epidemiol. 2008;167(7):875. University. 11. Haskell W, Lee I, Pate R, Powell K, Blair S, Franklin B, et al. Physical activity and public health: updated References recommendation for adults from the American 1. Wild S, Roglic G, Green A, Sicree R, King H. College of Sports Medicine and the American Global prevalence of diabetes: estimates for the Heart Association. Circulation. 2007;116(9):1423- year 2000 and projections for 2030. Diabetes care. 34. 2004;27(5):1047-53. 12. Mabry R, Koohsari MJ, Bull F, Owen N. A 2. Matheus ASdM, Tannus LRM, Cobas RA, Palma systematic review of physical activity and sedentary CCS, Negrato CA, Gomes MdB. Impact of diabetes behaviour research in the oil-producing countries on cardiovascular disease: an update. International of the Arabian Peninsula. BMC public health. journal of hypertension. 2013;2013. 2016;16(1):1003. 3. Mandil AM, Alfurayh NA, Aljebreen MA, Aldukhi 13. Alahmed Z, Lobelo F. Physical activity promotion SA. Physical activity and major non-communicable in Saudi Arabia: A critical role for clinicians and diseases among physicians in Central Saudi Arabia. the health care system. Journal of epidemiology Saudi Med J. 2016;37(11):1243. and global health. 2018;7:S7-S15. 4. Pettee G, Morrow J, Woolsey A. Framework for 14. Sparling PB, Snow TK. Physical activity patterns physical activity as a complex and multidimensional in recent college alumni. Res Q Exerc Sport. behavior. J Phys Act Health. 2012;9(Suppl 1), 2002;73(2):200-5. S11-S18. 15. Jalloun RA, Surrati AM. Physical Activity 5. Dunstan DW, Owen N. New exercise prescription: Pattern Among Female College Students at don't just sit there: stand up and move more, more Taibah University. International Journal of often: comment on" sitting time and all-cause Nutrition, Pharmacology, Neurological Diseases. mortality risk in 222 497 Australian adults. Arch 2020;10(3):137. Intern Med. 2012;172(6):500. 16. Majeed F. Association of BMI with diet and 6. Gill JM, Cooper AR. Physical activity and physical activity of female medical students at the prevention of type 2 diabetes mellitus. Sports Med. University of Dammam, Kingdom of Saudi Arabia. 2008;38(10):807-24. Journal of Taibah University Medical Sciences. 7. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya 2015;10(2):188-96. K, Adair-Rohani H, et al. A comparative risk 17. Al-Rethaiaa AS, Fahmy A-EA, Al-Shwaiyat NM. assessment of burden of disease and injury Obesity and eating habits among college students attributable to 67 risk factors and risk factor clusters in Saudi Arabia: a cross sectional study. Nutrition in 21 regions, 1990–2010: a systematic analysis journal. 2010;9(1):39. for the Global Burden of Disease Study 2010. The 18. Ghaith MM, Ibrahim MO. Dietary habits, eating lancet. 2012;380(9859):2224-60. practices and lifestyle pattern as predictors of 8. Lee I-M, Shiroma EJ, Lobelo F, Puska P, Blair SN, increased waist circumference amongst University Katzmarzyk PT, et al. Effect of physical inactivity of Umm Al-Qura female students: A cross-sectional on major non-communicable diseases worldwide: study (Obesity Associated Risk Factors). Medical an analysis of burden of disease and life expectancy. Science. 2020;24(101):351-9. The lancet. 2012;380(9838):219-29. 19. Desouky DS, Omar MS, Nemenqani DM, 9. Al-Hazzaa HM. Physical inactivity in Saudi Jabbar J, Tarak-Khan NM. Risk factors of non- Arabia revisited: a systematic review of inactivity communicable diseases among female university prevalence and perceived barriers to active students of the Health Colleges of Taif University. living. International journal of health sciences. International Journal of Medicine and Medical 2018;12(6):50. Sciences. 2014;6(3):97-107. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 271
20. Awadalla N, Aboelyazed A, Hassanein M, Khalil 21. Al-Hazzaa HM, Abahussain NA, Al-Sobayel HI, S, Aftab R, Gaballa I, et al. Assessment of physical Qahwaji DM, Musaiger AO. Physical activity, inactivity and perceived barriers to physical activity sedentary behaviors and dietary habits among Saudi among health college students, south-western Saudi adolescents relative to age, gender and region. Arabia. East Mediterr Health J. 2014;20(10):596- International Journal of Behavioral Nutrition and 604. Physical Activity. 2011;8(1):140. 272 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13861 Assessment of Lifestyle and Its Relation with Diabetes Mellitus in A Selected Under Privileged Community in Dhaka City, Bangladesh
Farhana Faruque Zerin1, Nasrin Akter1, A.K.M Shafiul Kadir2, Nishad Shahidullah3, Jahidul Bari4 1Research Fellow, Global Health Research Center (GHRC), Department of Public Health, Northern University Bangladesh (NUB), 2Lecturer, Department of Public Health, Northern University Bangladesh (NUB), Phone: +8801675746599, 3 M.Phil. Fellow (IBSc, RU), 4Assistant Professor, Department of Pediatric Dentistry, City Dental College and Hospital,5Resident surgeon, Hebei Medical University, China
Abstract Background: The effects of modernization of lifestyle have led to a dramatic increase in the prevalence of diabetes globally with very high rates in developing nations, particularly in Asia and the Pacific. The study was designed to show the link between lifestyle factors and having Diabetes Mellitus.
Methodology : A cross-sectional study conducted on a sample of 205 slum dwellers in Dhaka city, Bangladesh to assess lifestyle and its relation with diabetes mellitus. Respondents were interviewed by the pretested questionnaire. Proportion was presented by frequency and cross tabulation analysis. Associotion were analyzed by using Pearson’s chi-square (χ2) test.
Result: A statistically significant association is found between family history and having DM (p=0.12), where it is seen family history is a prominent risk factor of DM. Age group (p=0.00) and monthly family income (p=0.00) has a greater influence on having diabetes mellitus. Furthermore, respondents aged 39 - 50 years had a higher prevalence of diabetes. It was also seen that the prevalence of diabetes was significantly much higher among subjects of high-income families, while Physical activity (p=.002) and timely taking meal (p=0.00) greatly affect the diabetic curve. Moreover, smokers and alcohol consumers were more likely to develop diabetes mellitus in the community.
Conclusion:This study suggests that improving quality of life, dietary habit, health awareness through public health promotional education, mass media campaigns and treatment strategies are urgently needed to prevent the growing burden associated with diabetes.
Keywords:Diabetes Mellitus, Under Privileged Community, Lifestyle Factors
Introduction and estimated health expenditure was USD 760 billion.2 Prevalence of Diabetes dramatically increases The highest prevalence and susceptibility of type 2 globally because of modernization of lifestyle and aging diabetes has been well documented in Micronesian 3 4 of populations. Incidence rate is high in the developing and Polynesian Pacific Islanders, Native Americans, 5 nations, more specifically in Asia and Pacific.1 Indigenous Australians and Torres Strait Islanders, 6 According to the international Diabetes Federation and Asian Indians. In the context of present world, (2019), worldwide approximately 463 million adults the prevalence of diabetes is dramatically increased (20-79 years) were living with Diabetes and by the year & the dynamics of diabetes epidemic have changed 7 2045, it will rise to 700 million. It is estimated that 79% rapidly. Many countries have limited infrastructure of adults with diabetes living in low and middle-income for diabetes care and poor equipment for managing 8 countries. Diabetes caused 4.2 million deaths in 2019 diabetic patients. Genetic predisposition and behavioral and environmental influence are considered Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 273
as important risk factor in development of Diabetes self administered questionnaire was prepared for the Mellitus.9 Although genetic variant are not still poorly data collection based on socio-demographic, lifestyle, understood but obesity, physical activity and sedentary medical and other health related status of the study lifestyle are modifiable risk factors.10-17 According to subjects. Questionnaire that were included in the socio- Finnish Diabetes prevention study life style changes demographic and lifestyle related factors were body includes body weight control, physical activity and mass index (BMI), physical activity, having timely dietary modification intervention program lasting for meal, income, education, smoking status, alcohol intake, 3-6 years result in 58% reduction of diabetes risk.18-20 depression, family history, visiting to physician etc. No study has been conducted so far to show the link The low income, medium income and high-income between lifestyle factors and Diabetes Mellitus among households such as US$ 177.5, US$178 to 812 and the under privileged community people in Dhaka City, US$ 812, categorized monthly income.21 Knowledge Bangladesh. Findings from these studies will guide regarding of the study respondents was also included in the policy maker to emphasize the need for substantial the questionnaire. improvements of diabetes detection and treatments are Measures: A scoring system was used to measure needed in Bangladesh especially among disadvantaged the knowledge variables of the slum dwellers. Each populations. Improving detection, awareness, and correct answer was given a score of one mark and treatment strategies is urgently needed to prevent the zero for wrong or no answer. For multiple answers, growing burden associated with diabetes and it will score 1 was divided by total number of answer given possible to draw some tentative conclusions as to the by the respondents. Then the total obtained marks were causes of Diabetes Mellitus prevalence worldwide. converted into percentage. ≤50% knowledge score Methods and Materials considered as inadequate knowledge and >50 to 100% as adequate knowledge to analyze the knowledge level Study Description: A cross-sectional study was of the respondents.22 conducted among the slum dwellers at Mirpur area in Dhaka City Bangladesh to assess the life style related Data Analysis: Data were cleaned, edited, verified variables and its correlation with having Diabetes and coded to exclude any error or inconsistency. Analysis Mellitus. Significant portions of the city’s population was done using statistical package social science living in slums and provision of health services to software (SPSS) software version 21. All results p value these people faces many challenges due to their < 0.05 was considered as statistically strong significant. livelihood. Therefore, we select slum dwellers as our Descriptive analysis was applied for categorical study population. We exclude those who had a major variables. We did mean ± SD, Pearson’s chi-square psychiatric problem and only adults (27-62) were (χ2) test and found some amazing association between included in this study. diabetes mellitus and some of lifestyle predictors.
Sampling technique: We enrolled 250 respondents, Results 30 were excluded during run-in-phase due to inadequate An overview of socio- demographic characteristics adherence. Of 220 participants, 15 withdraw due to of the study respondents are: More than half of the lack of time or loss of interest. Finally, 205 respondents respondents were found in age group between 39-50 selected from 200 households, participated in this (51.7%) with a majority of the male gender (52.2%). study. Participant for this quantitative study were the As a Muslim country majority of the respondents were slum dwellers in Mirpur area, Dhaka. Sample size was Muslim (81.0%) while most of them were Married calculated using the formula n= z2pq/d2. Nonrandomized (82.9%). Most of the respondents belong to middle- Purposive sampling technique was applied to conduct income families (70.2%). 28.3% respondent did not the study. have any formal education and 18 % , 22.9% and Data Collection technique & instrument: Data were 30.7% respondents had primary , secondary and higher collected from the respondents through face-to-face secondary or above education respectively. When interview method. A pre-tested, semi-structured, and considering BMI according to the categories proposed 274 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 by the WHO, we found that more than half (51.2%) of Study revealed that more than half (66.8%) the respondents, BMI ranges were 23-30 and 48.8% respondents having DM though most (88.8%) of respondents had it was 18-22. 60 % of the respondents the respondents had adequate Knowledge regarding had positive family history of Diabetes Mellitus. (Table Diabetes Mellitus. (Table 3 & 4) 1) To identify the factors associated with having DM From the life style view of the study subjects, the study found a statistically significant association more than half (63.4%) of the respondents maintained between family history and having Diabetes Mellitus. physical exercise every day. It was also found that In addition, having DM is highly significant among 57.1% did not have meal timely and took extra salt the subjects who did not maintain physical exercise in meal (69.8%). Significant amounts (49.3%) of the regularly (P=.002) and did not take meal timely (P=.00). respondents were smoker where as alcohol abusers Furthermore, subjects belonging 51-62 years of age were were 12.2%. In addition, 29.8% respondents had more prone to have DM (P= 0.00) while DM found more mild sleeping disturbance. (Table 2) Moreover, study prominent among the subjects having high monthly observed the condition related to co-morbidities among family income (P=0.00). Another lifestyle related factor, the respondents. It was found that, 54.6% respondents smoking cigarette (P=0.03) has a greater influence have been suffering from cardiovascular diseases and on having Diabetes Mellitus. Study did not found between 86.6% , 40.2% ,30.4% , 26% and 6.3% of those statistically significant correlation between knowledge respondents suffering from Hypertension , Heart block, and having Diabetes Mellitus though a significant Heart failure , Rheumatic fever and Stroke respectively. number had adequate knowledge on DM. (Table 5)
Table 1: Socio-demographic characteristics of the respondents (n=205)
Characteristics Frequency (n) Percent (%)
27-38 55 26.8
Age 39-50 106 51.7
51-62 44 21.5
Non formal education 58 28.3
Primary 37 18 Education Secondary 47 22.9
Higher Secondary or above 63 30.7
Muslim 166 81 Religion Non-Muslim 39 19 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 275
Cont... Table 1: Socio-demographic characteristics of the respondents (n=205)
Low Income 24 11.7
Monthly family income Medium Income 144 70.2
High Income 37 18
Married/ Divorced/ Widowed 170 82.9 Marital Status Unmarried 35 17.1
18-22 100 48.8 BMI 23-30 105 51.2
Yes 123 60 Family History of Diabetes Mellitus No 82 40
Table 2: Lifestyle related factors of the respondent (n=205)
Characteristics Frequency (n) Percent (%)
Daily maintenance of physical Yes 130 63.4 exercise No 75 36.6
Yes 88 42.9 Having meal timely No 117 57.1
Yes 101 49.3 Smoking No 104 50.7
Yes 143 69.8 Taking extra salt in meal No 62 30.2
Yes 25 12.2 Alcohol Intake No 180 87.8
Severe 57 27.8
Moderate 49 23.9 Sleeping disturbance Mild 61 29.8
No 38 18.5
276 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3: Distribution of the respondents by having Diabetes Mellitus (n=205)
Having Diabetes Mellitus Frequency (n) Percent (%)
Yes 137 66.8
No 68 33.2
Total 205 100
Table 4: Distribution of the respondents by having knowledge regarding Diabetes Mellitus (n=205)
Having knowledge regarding Frequency (n) Percent (%) Diabetes Mellitus
Adequate knowledge 182 88.8
Inadequate knowledge 23 11.2
Total 205 100
Table 5: Factors associated with having Diabetes Mellitus among the study respondents
Having DM
Predictors Yes No χ2⁄p
(n) (%) (n) (%)
27-38 20 36.4 35 63.6
Age group 39-50 79 74.5 27 25.5 33.44/0.001s
51-62 38 86.4 6 13.6
Low income 13 6.3 11 5.4 Monthly family Medium income 95 46.3 49 23.9 20.505/0.001s Income High income 29 14.1 8 3.9
Yes 77 62.6 46 37.4 Family history of 2.48/0.12 DM No 60 73.2 22 26.8 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 277
Cont... Table 5: Factors associated with having Diabetes Mellitus among the study respondents
Yes 97 74.6 33 25.4 Maintenance of 9.72/0.002s physical exercise No 40 53.3 35 46.7
Yes 75 74.3 26 25.7 Cigarette Smoking 4.96/0.03s No 62 59.6 42 40.4
Yes 34 38.2 55 61.8 Having meal timely 58.15/0.001s No 103 88.8 13 11.2
Adequate knowledge 124 68.1 58 31.9 Knowledge on DM 1.24/0.27 Inadequate knowledge 13 56.5 10 43.5
*Chi-square analysis, s= significant
26 Discussion 2012. A cohort study from 1980 to 1996 found lack of exercise; a poor diet, current smoking, and abstinence This population based descriptive type cross from alcohol use were all associated with a significantly sectional study assessed the level of knowledge and increased risk of diabetes, even after adjustment for the level of Diabetes Mellitus, lifestyles, prevention and body-mass index. This study reflected similar scenario co-morbidities related status of the respondents selected for Bangladeshi socio-demographic region.27 as sample population. The study showed, maximum subjects were married and from middle income families Conclusion while more than half (60 %) of the respondents had family In the context of Bangladesh , Diabetes is now history of Diabetes Mellitus. In addition, a significant become a national health concern but treatment and amount subjects had Non-formal education. Quite control are quite low. This population based cross similar data found from an interventional study done sectional study suggests that those who lived in the in 2002.23 More than half of the respondents (57.1%) disadvantages regions in terms of education and did not have meal timely and 63.4% were maintaining economic profile were found lacking of diagnosis , physical exercise every day. 49.3% respondents were treatment and control of diabetes. The findings from smoker and 12.2 % respondents consumed alcohol. study suggest that substantial improvements of diabetes 69.8% respondent has been taking eating extra salt in detection and treatment are needed in Bangladesh their diet. Co-morbidities related findings of the study especially among disadvantaged populations. Changing subjects are little bit different from another studies lifestyle , diabetes awareness, dietary habits through well conducted in India.24 Although, maximum respondents designed public education and mass media campaigns had adequate knowledge regarding DM, more than half and treatment strategies is urgently needed to prevent the ware suffering from DM. This observation is likely to growing burden associated with diabetes. similar with the findings from another study conducted in Turkey, where it was found that nearly half (47.6%) Ethical Approval: American International respondents had moderate knowledge level on DM and University Bangladesh (AIUB) ethical approval maximum knew the accurate definition of DM while committee approved this study. more than half did not have DM.25 Study found family history as a prominent risk factor of DM. 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23. Knowler WC, Barrett-Connor E, Fowler SE, managing diabetes at school program. Journal of Hamman RF, Lachin JM, Walker EA, Nathan Clinical Research in Pediatric Endocrinology. 2012 DM. Reduction in the incidence of type 2 diabetes Dec;4(4):199. with lifestyle intervention or metformin. The New 26. Stumvoll M, Tschritter O, Fritsche A, Staiger England journal of medicine. 2002 Feb;346(6):393- H, Renn W, Weisser M, Machicao F, Häring H. 403. Association of the TG polymorphism in adiponectin 24. Ramachandran A, Mary S, Yamuna A, Murugesan (exon 2) with obesity and insulin sensitivity: N, Snehalatha C. High prevalence of diabetes interaction with family history of type 2 diabetes. and cardiovascular risk factors associated with Diabetes. 2002 Jan 1;51(1):37-41. urbanization in India. Diabetes care. 2008 Feb 21. 27. Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu 25. Aycan Z, Önder A, Çetinkaya S, Bilgili H, S, Solomon CG, Willett WC. Diet, lifestyle, and Yıldırım N, Baş VN, Kendirci HN, Ağladıoğlu SY. the risk of type 2 diabetes mellitus in women. Assessment of the knowledge of diabetes mellitus New England journal of medicine. 2001 Sep among school teachers within the scope of the 13;345(11):790-7. 280 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13862 Topical Anesthesia versus Hand Weight Bearing on Modulating Upper Limb Spasticity in Hemiplegic Children
1 2 3* 4 Heba A. Bahey El-Deen , Hala Ibrahim Kassem , Khaled Takey Ahmed , Khaled Ahmed Olama , Radwa S. Abdul-Rahman5 1Associate Professor, Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Jouf University, Kingdom of Saudi Arabia. Former Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Misr University for Science and Technology, Egypt. 2Professor, Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Delta University for Science and Technology, Egypt. 3Associate Professor, Department of Physical Therapy for Cardiopulmonary Disorders and Geriatrics, Faculty of Physical Therapy, Misr University for Science and Technology, Egypt, 4 Professor, Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt, 5 Lecturer, Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
Abstract Purpose: This study was conducted to compare between the effects of topical anesthesia and hand weight bearing on controlling upper limb spasticity in hemiplegic cerebral palsy children. Materials and Methods: Thirty hemiplegic cerebral palsy children from both sexes, ranging in age from 4 to 6 years with spasticity grade of 1 to 1+. The patients were assigned randomly into two groups (I and II). The range of motion of elbow and wrist extension and hand grip strength were determined before and after three months of treatment. Both groups received a designed exercise program, for one hour, 3 times / week for 3 successive months, in addition; group I received topical anesthesia on the affected upper limb for 30 minutes, while group II received a maintained weight bearing in diagonal extension position for 30 minutes. Results: Study results revealed significant improvement in all measuring variables of both groups when comparing their pre and post treatment mean values. Significant difference was observed in group II, when comparing the post treatment mean values of the range of motion of both groups. Conclusion: Topical anesthesia and hand weight bearing may be used for modulation of upper limb spasticity when combined with exercise program and increases the range of motion of elbow and wrist extension.
Keywords: Cerebral Palsy – Hemiplegia – Topical Anesthesia – Hand Weight Bearing.
Introduction impairment affecting one body sides. It is characterized by increased flexor tone of the affected upper limb, Cerebral palsy (CP) is a term used to describe any with great impairment of hand function.4 Physical neurological symptoms due to brain insult occurring early therapy techniques play a major role in restoration of in infancy causing permanent damage and disability. It hand function. Researchers are always trying to find is one of the most common causes of disability during out methods to inhibit flexor spasticity of the upper 1 the childhood. limbs, which affects their posture and consequently interferes with functional activities and hand function. The type of lesions in CP varies according to the 5, 3, 6 Benzocaine spray is a known chemical compound affected area in brain including; motor, sensory or which has been used as a topical anesthetic agent to mixed impairments. The motor impairment patterns reduce spasticity and improve gait patterns in spastic may be represented in the form of hemiplegia, diplegia, hemiplegic patients.7, 8, 9 triplegia or quadriplegia.2 Hemiplegia is one of the spastic forms of cerebral palsy accounting for 30% to On the other hand, weight bearing of the upper 3 40% of the total number. This spastic type causes motor extremity is required to develop controlled movements Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 281
of the proximal joints such as shoulder and elbow joints, Faculty of Physical Therapy, Cairo University. Study which is essential for well-controlled fine hand motions. registered on PACTR (PACTR 201911720095534). A Weight bearing exercises stimulate mechanoreceptors consent form was obtained and signed from each child’s within the joint surface, which is effective for joint parents before the beginning of the trial. stability.10 Instrumentation: The aim of this study was to compare between the Handheld dynamometer for measuring hand effect of topical anesthesia and hand weight bearing grip strength graded from zero to ninety kilograms on controlling upper limb spasticity in children with was used. The dynamometer handle could be easily hemiplegia. adjusted according to the size of the child’s hand. The Materials and Methods dynamometer has red and black detectors. When the child uses it, both detectors move together, but when it Subjects: is released, the black one returns and the red one gives Thirty hemiplegic CP children from both sexes (17 the reading. females and 13 males), ranging in age from four to six An electro goniometer was used to determine the years ( Χ 5±1.02) represented the sample of this study. range of motion of elbow and wrist extension. It consists They were recruited from the Pediatric out-patient clinic of a potentiometer fixed at the pivot point of fixed and of the Faculty of Physical Therapy, Cairo University. movable arms. The potentiometer was connected to Inclusion criteria: The degree of spasticity ranged a digital multi-meter to record the degree of angular from 1 to 1+ grades according to the modified Ashowrth displacement of each joint. scale.11 They had no structural deformities in the affected A benzocaine (20%) topical anesthesia spray and upper limbs with partial volitional control over the tumble forms (mat, wedges, roller and ball), for the antispastic muscles group. They had normal superficial application of the exercise program. skin sensation of the affected upper limb. All of them were able to understand verbal command and follow Procedures: instructions. Each child was asked to sit on an adjustable height Exclusion criteria: any previous history of orthopedic chair with back support. The head was maintained in injuries or other diagnosis as genetic disorders, metabolic mid-position with the trunk erect and fastened to the back disorders and brain tumors or history of botulinum of the chair by a belt. The hips and knees were flexed toxins infusion in spastic muscles of the affected upper 90 degrees with the feet fully supported on the ground extremity. in neutral position. The shoulder joint was maintained beside the body in neutral position, the elbow joint was The children were assigned randomly into two flexed 90 degrees, forearm in mid-position between groups of equal number (I and II) using closed envelope supination and pronation with the wrist joint in neutral method. Evaluation for each child was conducted before position. Each child was then asked to hold the handle and after three months of treatment. Group I received of the dynamometer and squeeze it as much as possible, topical anesthesia maintained for 30 minutes followed then release. The mean of three trials of the maximum by a designed exercise program, while group II received reading reached by the red detector of the dynamometer hand weight bearing with the limb maintained in was recorded. diagonal extension position for 30 minutes followed by the same exercise program given to group I. Range of motion of wrist extension: From sitting position, with the elbow flexed, forearm pronated and Study Design the wrist outside the plinth, the electro goniometer was A randomized double-blind experimental study placed on the ulnar aspect with the fulcrum on the ulnar design was conducted during the period from March styloid process, the fixed arm was parallel to the forearm 2019 to August 2019 at the pediatric outpatient clinic, and the movable arm was parallel to the ulnar aspect 282 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
of the hand. Then each child was asked to extend his/ For descriptive statistics, means and standard deviations her wrist and the best range of motion was determined were calculated for all variables pre and post intervention. starting from wrist flexion position. For analytical part, paired t-test was used to test the differences of means between pre and post trial of the Range of motion of elbow extension: Each child same group, while, independent sample t-test was used assumed supine lying position on a plinth. The electro to test for differences between means pre and then post goniometer was placed with the fulcrum on the lateral intervention of the two groups. The test was considered condyle of the humerus, fixed arm parallel to the lateral statistically significant if p-value <0.05. aspect of the upper arm and movable arm was parallel to the lateral aspect of the forearm. Each child was then Results asked to maximally extend his/her elbow to record the The collected raw data for the two groups I range from maximum flexion to maximum extension. (topical anaesthesia) and II (hand weight bearing) were The mean of three trials was then determined. statistically analyzed to show the mean and standard B- For Treatment: deviation of the hand grip strength and the range of motion of elbow and wrist extension, before and after Group I: Received Benzocaine 20% sprayed for three months of treatment. The obtained results revealed 15 seconds from a distance about 15cm over the whole no significant differences when comparing the pre- affected upper limb except its posterior aspect. The treatment mean values of the measuring variables for sprayed area was then massaged for 5 to 10 minutes. both groups. Comparing the pre and post treatment mean The limb was kept warm for 30 minutes before values of each group revealed significant improvement starting the exercise program. The exercise program in all measuring variables. Significant difference was included approximation, proprioceptive neuromuscular observed in favor of group II, when comparing the post facilitation, stretching exercises for all muscles liable to treatment mean values of the range of motion of elbow be tight and facilitation of grasp activities from sitting and wrist joints of both groups. However, no significant position. The exercise program was conducted for one difference was determined regarding hand grip strength. hour, 3 times / week for 3 successive months. Hand grip strength for both groups: Group II: This group received hand weight bearing, using placing technique. From side sitting position on a As shown in table (1), the pre-treatment mean values mat, the affected upper limb was maintained in extension of hand grip strength (kg) of groups I and II denoted diagonal position, in which the affected shoulder was no significant differences (P˃ 0.05). The pre and post extended and externally rotated, the elbow and wrist treatment mean values of hand grip for group I revealed joints were extended with fanning of the fingers and significant improvement (P< 0.05). Comparing the pre- thumb abduction. This position was maintained for 30 post treatment mean values of group II also revealed minutes then the same exercise program given to group significant improvement, (P< 0.05). However, the post- I was applied. Treatment technique for both groups were treatment mean values of hand grip strength (kg) for conducted three times/week for three months. groups I and II denoted no significant differences (P˃ 0.05). For statistical analysis:
SPSS version 16 was used in statistical analysis. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 283
Table (1): Pre and post-treatment mean values of hand grip strength (kg.) for groups I and II.
Group II Level of Hand grip strength (kg.) Group I t-test P-value significance
Pre ( Χ ±SD) 3.56 1.76 3.49 1.22 0.14 0.89 Non-significant
Post ( Χ ±SD) 4.96 1.33 5.12 1.46 0.35 0.73 Non-significant
T-test 2.494 3.32
P-value 0.022 0.003 ------
Level of significance Significant Significant
Range of motion of elbow extension for both groups:
As shown in table (2), the pre-treatment mean values of the range of motion of elbow extension of groups I and II showed no significant differences (P˃ 0.05). The pre and post treatment mean values of range of motion of elbow extension for group I revealed significant improvement (P< 0.0001). Comparing the pre- post treatment mean values of group II also revealed significant improvement. However, the post-treatment mean values of range of motion of elbow extension for groups I and II denoted significant differences in favor of group II (P< 0.0001).
Table (2): Pre and post-treatment mean values of range of motion of elbow extension (degrees) for groups I and II.
Range of motion of elbow Level of Group I Group II t-test P-value joint significance
Pre ( Χ ±SD) 94.65⁰ 3.96 93.78⁰ 3.44 0.75 0.46 Non-significant
Post ( Χ ±SD) 116⁰ 4.87 122.53⁰ 3.92 4.22 0.0004 Significant
T-test 13.17 21.35
P-value 0.0001 0.0001 ------
Level of significance Significant Significant
Range of motion of wrist extension for both groups I and II denoted no significant differences groups: (P˃ 0.05). The pre and post treatment mean values of range of motion of wrist extension for group I revealed As shown in table (3), the pre-treatment mean significant improvement (P< 0.0001). Comparing the values of the range of motion of wrist extension of pre- post treatment mean values of group II also revealed 284 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
significant improvement, (P< 0.0001). However, the post-treatment mean values of range of motion of wrist extension for groups I and II showed significant differences (P< 0.0001).
Table (3): Pre- and post-treatment mean values of range of motion of wrist extension (degrees) for groups I and II.
Level of Range of motion of wrist joint Group I Group II t-test P-value significance
Pre ( Χ ±SD) 36.38⁰ 3.24 37.65⁰ 3.54 1.16 0.26 Non-significant
Post ( Χ ±SD) 47.29⁰ 2.77 53.69⁰ 2.35 7.79 0.0001 Significant
T-test 9.9 14.6
P-value 0.0001 0.0001 ------
Level of significance significant Significant
Discussion the exercise therapy program, when comparing the post treatment results of the two groups with no significant This study was conducted to compare between the differences regarding handgrip strength. effects of topical anesthesia and hand weight bearing on modulating spasticity of the upper limb. Thirty Improvement observed in group I, who received hemiplegic children, diagnosed as spastic hemiplegic topical anesthesia in the form of benzocaine spray cerebral palsy represented the sample of the study. They (20%) on the affected upper limb agree with Sabbahi suffered from impaired hand function, especially the and De Luca.,8 who proved reduction in muscle tone and grip power. This comes in agreement with Greer et al improvement in the range of motion after the application 12 who reported, that the development of hand function of benzocaine spray over the spastic muscles. They occurs from birth to six years of age. Howard et al 13 attributed this improvement to be due to interaction stated that hemiplegia accounts one-third of cerebral between the skin receptors and their possible effect on palsied children. Researchers verified that precision of the alpha-gamma motor neurons activity, which has hand and finger movement develops in early childhood, been proven to be effective in controlling spasticity. well controlled in adulthood and are markedly impaired Therefore, improvement that occurred in-group I as a result of damage of the nervous system.14, 15, 16 receiving topical anesthesia may be attributed to the effect of topical anesthesia, which inhibited the nerve The results of the present study denoted that the endings of skin receptors and so blocking conduction goals of treatment were established to develop control of nerve impulses along the peripheral nerves and on the distal joints in the form of improvement in hand inhibiting the sodium channels, which are essential grip strength and range of motion of elbow and wrist for depolarization of nerve membranes and spread of extension. This improvement was observed in the two impulses along the nerve. This lead to inhibition of alpha groups (I and II) when comparing the pre and post and gamma motor neurons resulting in modulation of treatment mean values of the measuring variables. spasticity, which gave chance for the effectiveness of the Significant difference was observed in the range of exercise program. The findings of this study also comes motion of the affected wrist and elbow joints in favor of in agreement with Sabbahi and De Luca17, who recorded group II who received hand weight bearing in addition to Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 285 considerable modification of the movement parameters P.T.REC/012/002536), Cairo University – Egypt. noted within 30-45 minutes after application of topical Source of Funding: Self. anesthesia. The post-treatment results of group I are also 18 confirmed by the findings of Dhavalikar et al , who References revealed that temperature has an effect on the ability of the nerve to conduct impulses and the greatest change 1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, in nerve conduction velocity was seen at temperatures Bax M, Damiano D, Dan B, and Jacobsson B. A ranged between 29ºC and 37ºC. report: the definition and classification of cerebral palsy April 2006. Developmental medicine and High significant improvement observed in-group II child neurology. 2007; 109(Supplement, 109): may be attributed to the effect of hand weight bearing 8–14. of the affected upper limb, which produced sustained 2. Joghataei MT, Mohammad K, Rahgozar M, and static compression on its joints, working as constant Siadati S. Prevalence of Some Paralysis and stimulation of the proprioceptors inside the joints’ Limb Amputation Disabilities in Iran National capsule and tendons of the muscles. Constant stimulation Epidemiological SurveyArchives of Rehabilitation. caused a motor response in muscles and thus there was 2002; 3: 7–16. a better neuromuscular control, leading to controlling 3. Carmick J. Use of neuromuscular electrical spasticity via inhibition of flexor tone and improving stimulation and dorsal wrist splint to improve the the kinesthetic sense. The results of group II after three hand function of a child with spastichemiparesis. months of treatment come in agreement with Fetters Physical therapy. 1997; 77(6): 661–671. 19, who investigated the effect of static positioning via 4. Gordon AM., Bleyenheuft Y., and Steenbergen B. weight bearing on the affected upper limb during side Pathophysiology of Impaired Hand Function in sitting in spastic diplegic cerebral palsy and reported a Children With Unilateral Cerebral Palsy, Dev Med strong relationship between positioning and upper limb Child Neurol. 2013; 55 (Suppl 4):32-7. tasks as hand function. The post-treatment results also 5. Engsberg JR., Olree KS., Ross SA., and Park agree with Carey 20 who provided manual stretch of the TS. Quantitative clinical measure of spasticity in extrinsic finger flexor muscles in spastic hemiparetic children with cerebral palsy.Archives of physical subjects and recommended its use as an effective method medicine and rehabilitation.1996; 77(6): 594–599. for temporarily improving the control of finger extension 6. Waters PM and Van Heest A. Spastic hemiplegia of movement in those subjects. The post-treatment results the upper extremity in children.Hand clinics.1998; can be explained by the work of Kramer and Ann 14 (1): 119–134. MacPhail 21, who stated that there is a strong relationship 7. Wolf SL, and Minkwitz JA. Topical anesthetics: between proximal and distal motor function. Proximal effects on the Achilles tendon and H-reflexes. motor control is necessary for accurate placement of I. Able-bodied subjects. Archives of Physical hand as a distal motor function. Medicine and Rehabilitation.1989; 70 (7): 531– 536. Conclusion 8. Sabbahi MA, and De Luca CJ. Topical anesthetic- induced improvements in the mobility of patients Topical anesthesia and hand weight bearing could with muscular hypertonicity: Preliminary results. be used in addition to other methods of treatment for Journal of electromyography and kinesiology : improving hand function through increasing motor official journal of the International Society of control of the spastic muscles in hemiplegic cerebral Electrophysiological Kinesiology.1991; 1(1): 41– palsy children. 48. Conflicting of Interest: The authors declared that 9. Wilkinson DJ. Anaesthesia, BMJ. 1999; 318: S2- no conflict of interest related to this study. 7187. 10. Lee S, Cho S, and Kim K. The Effects of Weight- Ethical Approval: The study was ethically Bearing Exercise on Upper Extremity Activities approved from the Institutional Ethical Committee (No: Performance in the Female Stroke Patients, 286 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
International Journal of Contents. 2013; 9(1): 65- 16. Eliasson AC., Gordon AM., and Forssberg H. 70. Impaired anticipatory control of isometric forces 11. Kaya T., Karatepe, A G., Gunaydin, R., Koc, A. and during grasping by children with cerebral palsy. Ercan, U.A. Inter-rater reliability of the Modified Developmental medicine and child neurology.1992; Ashworth Scale and modified Modified Ashworth 34(3): 216–225. Scale in assessing post stroke elbow flexor 17. Sabbahi MA and De Luca CJ. Topical anesthesia: spasticity. International Journal of Rehabilitation modulation of the monosynaptic reflexes by Research. 2011; 34(1): 59-64. desensitization of the skinElectroencephalography 12. Greer S., Bauchner H., and Zuckerman B . The and Clinical Neurophysiology.1982; 54(6): 677– Denver Developmental Screening Test: how good 688. is its predictive validity? Developmental medicine 18. Dhavalikar M., Narkeesh A., and Gupta N. Effect and child neurology.1989; 31(6): 774–781. of Skin Temperature on Nerve Conduction Velocity 13. Howard J., Soo B., Graham HK., Boyd RN., Reid and Reliability of Temperature Correction Formula S., Lanigan A., Wolfe R., and Reddihough DS. in Indian Females, Journal of Exercise Science and Cerebral palsy in Victoria: motor types, topography Physiotherapy. 2009; 5(1): 24-29 and gross motor function.Journal of paediatrics and 19. Fetters L. Measurement and treatment in cerebral child health.2005; 41(9-10): 479–483. palsy: an argument for a new approach.Physical 14. Forssberg H., Eliasson AC., Kinoshita H., therapy.1991; 71(3): 244–247. Johansson RS., and Westling G. Development of 20. Carey JR. (1990): Manual stretch; Effect on finger human precision grip I: Basic coordination of force. movement control and force control in stroke Experimental brain research.1991; 85(2): 451–457. subjects with spastic extrinsic finger flexor muscles. 15. Gordon AM., Forssberg H., Johansson RS., and Archives of physical medicine and rehabilitation. Westling G. The integration of haptically acquired 1990; 71(11): 888–894. size information in the programming of precision 21. Kramer JF., and Ann MacPhail HE. Relationships gripExperimental Brain Research.1991; 83(3): Among Measures of Walking Efficiency, 483–488. Gross Motor Ability, and Isokinetic Strength in Adolescents With Cerebral Palsy.1994; Pediatric Physical Therapy, 3-9. DOI Number: 10.37506/ijphrd.v12i1.13863 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 287 Effect of Hydro-Aromatherapy on Heart Rate in Heart Failure Patients
Huwaina Af’idah 1, Syafruddin Ilyas 2, Ikhsanuddin Ahmad Harahap 3 1Master Student, Faculty of Nursing, Universitas Sumatera Utara, Indonesia, 2 Lecturer, Faculty of Mathematics and Science, Universitas Sumatera Utara, Indonesia, 3Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Indonesia
Abstract Objects: to determine the effect of hydro-aromatherapy on heart rate in patients with heart failure.
Methods: This study was a quasi-experiment pretest-posttest with two groups. Thirty-two respondents were selected by consecutive sampling with inclusion and exclusion criteria. The intervention was given a warm feet soak with aromatherapy, while the control only had a warm feet soak. Pulse oximetry was used to measure heart rate. Data were analyzed using a dependent t-test and independent t-test.
Results: there was a statistically significant heart rate difference before and after in intervention (p<0.000), and also there was a statistically significant heart rate difference before and after in the control group (p<0.0005). In the study in the intervention group after the treatment, a warm feet soak with aromatherapy was decreased heart rate by an average of 78.69 (SD=14.63). Whereas in the control group after the treatment a warm feet soak was also decreased heart rate by an average of 85.31 (SD=5.12).
Conclusion: Both treatments a warm feet soak with and without aromatherapy were decreased the heart rate, but perhaps with aromatherapy will be improved patients’ comfort.
Keywords: Hydro-aromatherapy; Heart failure; Heart rate
Introduction disorders that occur due to systemic dams that affect the functioning of the heart(3). Heart failure (HF) is a pathophysiological condition where the heart’s function as a pump is no longer able to In this case, there are two kinds of management of meet the needs of blood throughout the body for tissue cardiovascular diseases, namely pharmacological and metabolism(1). Heart disease ranks the third-highest non-pharmacological. Pharmacological management number of patients in hospitals in Indonesia. While the is with drugs and medical therapy, and non- number of new patients with inpatient heart failure in pharmacological management without medical drugs one of the North Sumatra has increased in recent years, such as hydrotherapy and aromatherapy. Hydrotherapy with 238 patients in 2014, 248 patients in 2015, and 295 is a therapy using water as a medium. One type of patients in 2016(2). hydrotherapy is to soak feet with warm water. Warm water scientifically has physiological effects on the HF results in a decrease in cardiac output which can body, namely in blood vessels where the warm water be a serious problem in cardiovascular function related temperature makes the circulation of blood vessels to the entire body system(3). Therefore, a decrease in smooth because of the vasodilation of blood vessels(5). pathophysiological cardiac output can cause dangerous physiological effects including cardiogenic shock, Wulandari said that hydrotherapy by soaking feet stopping breathing until death(4). HF results in various with warm water is beneficial to reduce blood pressure, problems include heart rhythm disorders, blood pressure, heart rate, increase circulation, reduce edema, increase heart rate, discomfort, peripheral tissue perfusion muscle relaxation, and increase comfort(6). Koike et 288 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
al. found that there was a significant decrease in blood sensitive to warm water; 8) no disturbance in the smell, pressure, heart rate as physiological indicators after and 9) no history of allergies to aromatherapy. Exclusion warm water foot bath therapy(7). Nauman et al. obtained criteria, namely: 1) unilateral reasons for stopping the result that foot bath therapy with warm water affects participation in the study; and 2) respondents who died the heart rate(8). Based on the description above, the or did not continue treatment until completion of therapy. researchers are interested in determining the effect For the hydro-aromatherapy group (intervention), the of hydro-aroma therapy on heart rate in heart failure intervention was to soak feet with warm water mixed patients. with rose aromatherapy essential oil in a bucket with a water temperature of 35-450C for 10 minutes, while the Methods hydrotherapy group (control) was given the intervention This study was a quasi-experiment pretest-posttest to soak feet in warm water only without mixing with with two groups. Thirty-two respondents were selected rose aromatherapy essential oil in a bucket with water 0 by consecutive sampling with inclusion and exclusion temperature 35-45 C for 10 minutes. The heart rate criteria. Inclusion criteria, namely: 1) respondents with observation sheet was a pre-intervention note sheet and the medical diagnosis of heart failure in the inpatient post-intervention heart rate values per minute from the room at Medan City Hospital with NYHA II and III measurement results of the pulse oximeter (Operating classification; 2) willing to participate in research, 3) in Manual of Fingertip Pulse Oximeter Version 02) to a conscious condition and able to communicate well; 4) respondents both in the intervention group and the able to sit; 5) there is not a history of peripheral vascular control group. Data were analyzed using a dependent disease or neuropathy disorders due to diabetes; 6) there t-test and independent t-test. are no wounds and inflammation in the leg area; 7) not
Results Table 1 shows the distribution and presentation of the demographic characteristics of respondents and the factors related to this study.
Table1. demographic characteristics of respondents and related factors (n=32)
Intervention (n=16) Control (n=16) Variable f % f %
Age 0 1 Early Adulthood 26-35 years old 0 6.30 4 1 Late Adulthood 36-45 years old 25 6.30 3 3 Early Elderly 46-55 years old 18.80 18.80 8 10 Late Elderly 56-65 years old 50 62.50 1 1 Old man >65 years old 6.20 6.30
Mean + SD 55.06 + 8.71 55.06 + 11.34 min-max 33-68 41-84
Gender Male 11 68.80 10 62.50 Female 5 31.20 6 37.50 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 289
Education 1 6.30 Primary School 4 25 1 6.30 Junior High School 3 18.80 10 62.50 Senior High Scholl 3 18.80 4 25 0 0 Diploma/ Bachelor 5 31.30 Magister 1 6.30
Profession 2 12,50 Farmer 3 18,80 1 6,30 Driver 1 6,30 1 6,30 Trader 1 6,30 3 18,80 Government Employees 2 12,50 4 25 Entrepreneur 1 6,30 0 0 5 31,30 General Employees 3 18,80 Jobless/ Housewife/ Retired 5 31,30
Long suffered 4 25 Acute <5 years (60 months) 6 37.50 12 75 Chronic >5 years (60 months) 10 62.50 31.44 + 26.63 Mean + SD 47.94 + 65.98 1-96 min-max 1-216
Family History 14 87.50 Yes 9 56.30 2 12.50 No 7 43.80
History of Disease 8 50 Hypertension 6 37.50 0 0 Bronchopneumonia 1 6.30 1 6.30 Chronic Obstructive Pulmonary Disease 0 0 5 31.30 Hypertension + Diabetes Mellitus (DM) 2 12.50 1 6.30 Hypertension + Kidney Illness 0 0 1 6.30 0 0 Hypertension + COPD 0 0 0 0 DM + Pneumonia 1 6.30 0 0 Pneumonia 1 6.30 0 0 Hemorrhoid 1 6.30 No 4 25 290 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Lifestyle History 10 62.50 Smoke 6 37.50 4 25 Yes 12 75 No 13 81.30 0 0 Alcohol 3 18.80 16 100 Yes 2 12.50 7 43.80 No 9 56.30 14 87.50 Regular Exercise 7 43.80 0 0 Yes 9 56.30 16 100 No 12 75 Eat Regularly 4 25 Yes 6 37.50 No 10 62.50 Enough Rest Yes No
1 6.25 BMI 15 93.75 Underweight 0 0 0 0 Normal 14 87.50 0 0 Overweight 1 6.25 Obesity 1 6.25
Pain Scale 15 93.80 Moderate 10 62.50 1 6.20 Severe 6 37.50 5.19+0.9 Mean + SD 6.06+1.29 4-7 min-max 4-8
Pain Location 16 100 Chest 16 100
Pain Metastases 9 56.20 Back 7 43.80 2 12.50 2 12.50 Neck 3 18.80 3 18.80 Chest 3 18.80 0 0 Stomach 1 6.30 0 0 Neck and Hand 1 6.30 Neck and Back 1 6.30
Classification of CHF (NYHA) 5 31.30 Class II 7 43.80 11 68.80 Class III 9 56.30
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Table 2 shows that the study found that in the average of 78.69 (SD=14.63). Whereas in the control intervention group, research respondents in the pre- group, the average heart rate before treatment was 87.31 treatment stage had a heart rate with an average of 83.06 (SD=4.88), and after the treatment of feet soaking with (SD=14.03). Whereas in the stage after the treatment of warm water without aromatherapy mixed also decreased feet soaking with warm water mixed with aromatherapy by an average of 85.31 (SD=5.12). it was found that the average heart rate decreased by an
Table 2. effects of hydro-aromatherapy on heart rate before and after hydro-aromatherapy (n=32)
Intervention (n=16) Control (n=16)
Variable
Mean + SD min-max Mean + SD min-max
Heart rate Before 83.06+14.03 55-112 87.31+4.88 78-96
Heart Rate After 78.69+14.63 53-100 85.31+5.12 78-95
Table 3. shows that in the intervention group there were significant differences in heart rate between before and after the intervention (p=0.00). While in the control group, also found a significant difference in heart rate between before and after treatment (p=0.02). This shows that soaking the feet with warm water has a significant effect (p <0.05) can reduce heart rate in patients with heart failure with or without aromatherapy.
Tabel 3. differences in the effects of hydro-aromatherapy on heart rate
Intervention (n=16) Control (n=16) Variable Mean Score Mean Score t (sig) t (sig) Difference (SD) Difference (SD)
HR 4.37 (10.43) 1.67 (0.00) 2.00 (4.70) 1.70 (0.02)
Discussions the control group (62.5%) included patients with chronic heart failure with a long history of suffering> 60 months In the intervention group, based on the age of half (5 years). And most study respondents also had a history the respondents (50%) were late elderly with age 56-65 of comorbidities such as hypertension in the intervention years and the average age of respondents was 55.06 with group (37.5%) and control (50%). a standard deviation of 11.34. The same was true for the control group, which was 62.5% who were late elderly This is in agreement with the results of Kao et al. with the average age of respondents being 55.06 + 8.71. study which found that from 91 samples of patients with Two-thirds of respondents (68.8%) from the intervention heart failure the average age was 66.74 + 12.23 years(9). and control groups (62.5%) were male. More than half The majority of participants were male (57.1%), married of the respondents in the intervention group (75%) and (62.6%), not working (73.6%), and not attending 292 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
school or only elementary school (60.5%). The largest strength from heart rate variability reflecting the activity proportion of participants was in NYHA Classification of the parasympathetic nervous system by inhaling II (40.7%), comorbidities suffered by participants 71.4% aromatherapy yuzu oranges(12). Furthermore, Kenia and hypertension, 50.5% coronary artery disease, and 31.9% Taviyanda also found that aromatherapy for 10 minutes diabetes. can significantly reduce systolic blood pressure and diastolic blood pressure, with a mean decrease in systolic This study found that in the intervention group, and diastolic values of 10.63 mmHg and 10.18 mmHg before treatment had a heart rate with an average of 83.06 and a maximum value for the systolic and diastolic (SD = 14.03). Whereas after treatment, the respondent’s blood pressure of 28.00 mmHg and 20.00 mmHg with heart rate decreased by an average of 78.69 (SD = aromatherapy(13). 14.63). Whereas in the control group, the average heart rate before treatment was 87.31 (SD = 4.88), and after Conclusions the treatment of foot soaking with warm water without The results of this study indicate that there was an aromatherapy mixed also decreased by an average of effect of hydro-aroma therapy on decreasing heart rate in 85.31 (SD = 5.12). patients with heart failure. This is also by Wulandari’s which states that Conflict of Interest: Nil hydrotherapy by soaking feet with warm water is beneficial for lowering blood pressure, increasing Source of Funding: No funding in this is a study circulation, reducing edema, increasing muscle relaxation(6). Based on the results of research Nauman et Ethical Consideration: This research has passed the al. therapy soak feet with warm water effect on handling test of ethics from the health research ethics committee depression and heart rate in patients with depressive of the Nursing Faculty of Universitas Sumatera Utara, disorders(8). with registration number 1562/VIII/SP/2018.
This study shows that soaking feet with warm water References can reduce heart rate in heart failure patients with or 1. Price SA, Wilson LM. Pathophysiology: Clinical without aromatherapy. Similar to the results of Harada Concepts of Disease Processes 6th Edition. United et al. said that soaking feet can be combined with States: Mosby. 2005 herbs, salts, moisturizers, or other ingredients added 2. Kemenkes. Hasil Utama Riskesdas. Jakarta. to containers containing warm water and used to soak 2018. Accessed from https://www.kemkes. (10) feet . From the results of the study, it was found that go.id/resources/download/info-terkini/hasil- soaking foot warm water mixed with salt can increase riskesdas-2018.pdf the temperature of the fingers and locally increase the 3. Udjianti W. Cardiovascular Nursing. Jakarta: temperature of the skin, but overall it warms the body, Salemba Medika. 2011 affects blood pressure, and besides it also has an effect 4. Smeltzer C, Bare G. Buku Ajar Keperawatan on increasing peripheral blood circulation. Medikal Bedah Brunner & Suddarth. Jakarta: EGC. Aromatherapy is also beneficial for the patient’s 2011 vital signs status. This is by the results of research 5. Ilkafah. Differences in the Decrease in Elderly by Taheri et al. Aromatherapy affects physiological Blood Pressure with Anti-Hypertension Medication parameters on the awareness of inpatients in the ICU and Warm Water Bath Therapy in the Puskesmas hospital significantly reducing the patient’s vital sign in Work Area Between Tamalanrea Makassar. Pharmacon Pharmaceutical Scientific Journal- the intervention group compared to the control group by UNSRAT. 2016; 5(5):2302-2493. DOI: https://doi. measuring systolic and diastolic blood pressure, pulse org/10.35799/pha.5.2016.12194. rate, respiratory rate, and arterial blood oxygen saturation p <0.05 using aromatherapy mint(11). Matsumoto also 6. Wulandari P, Arifianto, Sekarningrum D. Pengaruh Rendam Kaki Menggunakan Air Hangat dengan explained that aromatherapy significantly reduced blood Campuran Garam dan Serai terhadap Penurunan pressure, heart rate, and increased the frequency of Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 293
Tekanan Darah pada Penderita Hipertensi. 2016. Effects of Footbath with Salt. Hiroshima Journal of Accessed from http://ejournal.umm.ac.id. Medical Science. 2014;63 (1-3): 1-5. 7. Koike Y, Kondo H, Kondo S, Takagi M, Kano Y. 11. Taheri S, Firouzkouhi M, Abdollahimohammad Effect of Steam Foot Spa on Geriatric Inpatients A, Sadegei K, Shahrakivahed A. Effect of with Cognitive Impairment: a Pilot Study. Aromatherapy Massage with Mint Essential Oil on Clinical Intervention in Aging. 2013; 8: 543-548. Physiological Parameters of Concussion Patients DOI: 10.2147/CIA.S44005 Hospitalized in Intensive Care Unit: A clinical trial. 8. Naumann J, Grebe J, Kaifel S, Weinert T, Sadaghiani Scholars Research Library. 2016; 8(13): 274-279. C, Huber R. Effect of Hyperthermic Baths on Accessed from www.scholarsresearchlibrary.com Depression, Sleep and Heart Rate Varibility in 12. Matsumoto T, Kimura T, Hayashi T. Aromatic Patients with Depressive Disorder: A Randomized Effects of a Japanese Citrus Fruit-Yuzu on Clinical Pilot Trial. BMC Complementary and Psychoemotional States and Autonomic Nervous Alternative Medicine. 2017; 17(172): 1-9. DOI: System Activity During The Menstrual Cycle. 10.1186/s12906-017-1676-5. Biopshicososcial medicine. 2016; 10(11):1-11. 9. Kao C, Tseng L, Lin W, Cheng S. Association of DOI: 10.1186/s13030-016-0063-7. Psychosocial Factors and Heart Failure Patients. 13. Kenia NM, Taviyanda D. Pengaruh Relaksasi Western Journal of Nursing Research. 2014; 36(6): (Aromaterapi Mawar) terhadap Perubahan Tekanan 769-787. DOI: 10.1177/0193945913505922. Darah pada Lansia Hipertensi. Jurnal STIKES. 10. Harada T, Iwakawa Y, Ikeda H, Ishizaki F, 2013;6(1): 84-98. Accessed from http://www. Aoi S, Nitta Y, Yoshida A, Tamura N., et al. puslit2.petra.ac.id. Thermographic Study on the Preservability of Heat 294 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13864 Implementation of Effective Nurse Communication in Hospital Through Electronic Nursing Documentation (END)
I Wayan Gede Saraswasta1, Rr. Tutik Sri Hariyati2, Krisna Yetti2 , Tuti Nuraini2 1Master Student in Nursing Leadership and Management Program, Faculty of Nursing, Universitas Indonesia,2Basic and Fundamental of Nursing Department, Faculty of Nursing, Universitas Indonesia
Abstrct Introduction: The low quality of documented information becomes the main cause of failure in conducting effective communication. The implementation of electronic nursing documentation improves the quality of information so that it facilitates the implementation of effective communication. Objective: To identify the implementation of effective communication of nurses in hospitals through electronic nursing documentation. Method: A cross sectional design with 243 nurses as total sample. The effective communication instrument consists of 52 statements. The validity test result is in the range of 0.396-0.946 and the reliability test result is Cronbach’s alpha 0.965. The data are collected online using Google form application. Results: Implementation of effective communication of nurses was 80.18% of the maximum value. The highest effective communication occurred on patient discharge while the lowest conducted in receiving messages by phone. The implementation of effective communication during the nursing process is 78.70%. Conclusion: The implementation of electronic nursing documentation could facilitate the implementation of effective communication for nurses in hospitals. However, effective communication during the nursing process is potentially requiring more improvement. The recommendation is that the nursing manager should encourage the implementation of effective communication through the utilization of electronic nursing documentation.
Keywords: Electronic nursing documentation, effective communication, nursing process
Introduction effectively. This causes the majority of patients feel dissatisfied with the information provided by nurses, The quality of nursing care provided to patients even by 80% of patients do not know the name of depends on the ability of nurses to carry out effective the nurse who cared for him while in hospital (5,6). communication (1). The competence of nurses to Ineffective communication can endanger the patient and communicate effectively can reduce errors in providing care professional (7). Failure to communicate effectively care to enable the provision of safe and quality care contributes to 32% of malpractice events, undesirable (2). In addition, effective communication helps patients events and patient deaths (3,8). and families to understand how their health conditions, goals and treatment plans will be provided to patients Failure to carry out effective communication (3,4). This shows that the implementation of effective occurs because important information is sometimes not communication plays a very important role in providing documented, inaccurate and cannot be accessed quickly quality care. (9,10). Therefore nurses must document patient information accurately, timely, briefly, and effectively(11) . Advances in Some studies state that the majority of nurses technology, information and communication are driving in providing care to patients do not communicate the implementation of electronic nursing documentation to improve the completeness, relevance and quality of Corresponding author: nursing documentation. So that it can provide quality Rr. Tutik Sri Hariyati information to facilitate the implementation of effective [email protected] communication (12–15). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 295
Hospital X is a type B hospital owned by the DKI female (76.50%), vocational nurse (67.50%), have 1-4 Jakarta government that has developed and used an years of service (45,30%), had never attended training electronic nursing documentation since it first operated. (47.30%), contract status (87.20%), career ladder of However, the implementation of effective communication Level I (33.3%) & Level II (40.30%) and mostly as through an electronic nursing documentation is not yet nurses staff (68.70%). known. The statement became the basis of the importance Table 2 (attached) shows the average of conducting research to identify how to implement implementation of effective communication of nurses effective communication of nurses in hospitals through at Hospital X Jakarta is 166.77 (80.18% of maximum Electronic Nursing Documentation (END). value) and it is believed that 95% of the average Method effective communication implementation of nurses is between 166.47 to 167.08. The results of the analysis of This study used a cross sectional design with a total each item of effective communication implementation sample of 243 out of a total of 477 nurses working at at the hospital showed the highest average effective the X Hospital in Jakarta. Determination of the sample communication implementation at the time the patient using simple random sampling and proportional left was 86.54% of the maximum value and the lowest sampling techniques by providing equal opportunities was effective communication when receiving messages for all members of the target population to be selected by telephone at 77.05 from maximum value. as research samples. Determination of the number of samples in each room using the proportional sampling Discussion formula that is, the total population in each room Implementation of effective communication carried multiplied by the number of samples divided by the total out by nurses plays a very important role in providing population. quality nursing care (1,16). The implementation of The research instrument consisted of 52 statements an electronic nursing documentation facilitates the regarding the implementation of effective communication implementation of effective communication (10). The which consisted of effective communication at the time average implementation of effective communication of transfer of patients, delivery of nursing care, hand over of nurses at X Hospital Jakarta was 80.18% of the between shifts, reporting of critical examination results, maximum value indicating the majority of nurses had urgent conditions, between health care professional, communicated effectively. The implementation of receiving patients by telephone and effective effective communication supports nurses in making communication when patients discharge. The instrument the right decisions according to the patient’s condition in this study was developed by researchers based on the (17). Communication by nurses is considered effective if 2018 Hospital Accreditation Standards and several other done in a timely, accurate, complete, not confusing and references. The results of the validity and reliability can be understood by the recipient of information so that of the instrument are 0.396 - 0.946 (Cronbach’s alpha it can reduce errors in providing nursing care (7,18). 0.965). These results support several studies which state that This study has obtained a certificate of ethical the application of an electronic based documentation review pass from the Ethics and Research Committee system helps nurses to collect, analysis, transfer and of the Faculty of Nursing, University of Indonesia with access information quickly and accurately so as to number SK-48/ UN2.F12.D1.2.1/ETIK.FIK.2020 and facilitate the implementation of effective communication has received a permit from the Hospital Director to make (19–21). The results of research conducted by Orcajada research data. Data collection was done online using the Muñoz et al. (2020), also stated that nurses have relatively Google form application. good abilities in conducting effective communication. This can be seen from the ability of nurses to provide Result clear and easily understood information to patients and Table 1 (attached) shows the average age of nurses at can involve patients in making decisions. X Jakarta Hospital which is 29.52 years, the majority are 296 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
In contrast to studies conducted by Lotfi et al. showed an average of 78.70% of the maximum value. (2019) and Tran et al. (2020), states that nurses who Effective communication carried out by nurses in have the ability to carry out effective communication providing care will affect the therapeutic relationship are only 12%. This causes the majority of nurses who and the quality of care provided to patients. The work in hospitals do not communicate effectively in therapeutic relationship between nurses and patients is providing care to patients. Failure to carry out effective a core component of nursing care (28). Implementation communication can cause delay or neglect in providing of effective communication nurses during the nursing nursing care (11). Therefore, it is important for nurses process which reached 78.70 of the maximum value to overcome the factors that hinder the effective has the potential to be improved because 80% of errors implementation of communication both at the individual in providing care are caused by the implementation of level, health facilities and system improvements so ineffective communication (3). The safety and quality that it can improve the implementation of effective of care provided to patients are the main aspects communication carried out by nurses (23). and objectives of an effective health care system. Therefore increasing the implementation of effective Nurses need complete, relevant, clear (easy communication is one of the goals of patient safety that to understand), concise and timely information to must be carried out by nurses in providing quality care communicate effectively. Implementation of effective (29). communication in providing nursing care to patients will improve the quality of care and patient satisfaction The results of the analysis of the implementation (1,24). Implementation of effective communication of effective communication during the handover carried out by nurses at the hospital includes effective between nurses showed an average of 78.02% of the communication when transferring patients, carrying maximum value. Effective communication carried out out the nursing process, handover between shift nurses, by nurses during handover between shifts has a very receiving messages by telephone, reporting critical close relationship with the continuity of quality and examination results, communication during urgent patient safety (30). The implementation of ineffective conditions, communication between health professionals communication in handover between shifts is a major as well as communication when the patient discharge. factor that contributes to unwanted events, including sentinel events that cause danger or death to patients The results of the analysis of the implementation (3). The use of the system in transferring nurses between of effective communication at the time of transfer of shifts can apparently improve the implementation of patients showed an average of 82.96% of the maximum effective communication (2). value. Implementation of effective communication when transferring patients is necessary to prevent The results of the analysis of the implementation of errors in providing patient information. The patient effective communication when receiving messages by transfer process is an important aspect of providing telephone showed an average of 78.19% of the maximum health services according to the patient’s needs (25). value. Nurses play a very important role in the success The success and security of the transfer of patient of patient care in the hospital through coordination information is very dependent on the ability of nurses with other care professionals. The use of the telephone to communicate effectively (26). Implementation of is one option that can be used to coordinate between effective communication at the time of transfer of nurses and between health professional (31). However, patients who reach 82.96% of the maximum value is communication carried out by telephone often creates very important to ensure continuity of care provided to errors and is ineffective. Different accents, dialects and patients. Continuity of information in providing care is pronunciations can make it difficult for the recipient of an important factor to ensure quality and patient safety the message to understand the information conveyed (27). by the message giver (3). Based on the accreditation standard of patient safety goals, it is stated that messages The results of the analysis of the implementation delivered by telephone must be written in full, re-read of effective communication during the nursing process by the message recipient, and confirmed by the message Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 297
provider to enhance the implementation of effective nurses’ positive perceptions of communication with other communication by telephone between the health care giver professionals (24). Effective communication professional (7). between health team members is essential for safe and high-quality patient care (37). The results of the analysis of the implementation of effective communication in the reporting of critical The results of the analysis of the implementation examination results showed an average of 78.50% of effective communication at the time the patient left of the maximum value. The ability to communicate showed an average of 86.54% of the maximum value. and make decisions together based on the results of Effective communication when patients go home plays critical examinations is one of the challenges for health an important role in maintaining continuity of patient professional (32). Nurses as health professional must have care and therapeutic relationships between nurses the competence to communicate effectively with other and patients (38). Effective communication is the core PPAs in reporting the results of critical examinations foundation of the therapeutic relationship between health (33). This must be supported by the organization by workers and patients and is essential for Patient-cantered determining how critical value reporting procedures are, care. Patient-cantered communication enables the such as who should report and receive the critical value development of therapeutic relationships, which helps from the results of diagnostic tests. The report must then health care providers implement smart, sensitive and be documented in full in the patient’s medical record (7). collaborative approaches to communicate with patients The use of electronic nursing documentation in several about treatment plans after discharge from hospital (39). hospitals in reporting the results of critical examinations in fact can improve effective communication (34). Conclusion Implementation of effective communication The results of the analysis of the implementation performed by nurses plays a very important role of effective communication during urgent conditions in providing quality nursing care to patients. The showed an average of 78.37% of the maximum value. implementation of an electronic nursing documentation Submission of information accurately and on time facilitates the effective communication of nurses in is very necessary in urgent conditions so that the hospitals. Implementation of effective communication message delivered can be understood properly (7). The nurses include effective communication when implementation of effective communication during transferring patients, implementing the nursing urgent conditions certainly has challenges and obstacles process, handover between nurses’ shifts, receiving that are higher than normal conditions. Information messages by telephone, reporting critical examination exchange in urgent conditions must be done quickly and results, communication during urgent conditions, precisely so as to minimize the possibility of negative communication between health care professionals and impacts. Nurses in providing care to patients during communication to when the patient discharge. urgent conditions must make decisions quickly in (35,36) accordance with patient needs . The implementation of an electronic nursing documentation helps nurses to collect, analysis, transfer The results of the analysis of the implementation and access information quickly and accurately so as to of effective communication between health care facilitate the implementation of effective communication. professionals showed an average of 81.03% of the Therefore, nursing managers must encourage the use maximum value. Effective communication between of electronic nursing documentation to facilitate the care professional professionals is an important factor implementation of effective communication. influencing the quality of care provided to patients. Failure to carry out effective communication among “Ethical Clearance taken from the Ethics and care professionals is a major cause related to side effects Research Committee of the Faculty of Nursing, or errors in patient care that can reduce the quality of University of Indonesia with number SK-48/ UN2.F12. (3,27) nursing care . These results support the research D1.2.1/ETIK.FIK.2020.” conducted by Yaya Wang et al. (2018), which explains 298 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
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Iwan Purnomo Aji1, Fikri Rizaldi2 1General Practitioner, Semen Gresik Hospital, Gresik,East Java, Indonesia, 2General Urologist, Semen Gresik Hospital, Gresik,East Java, Indonesia
Abstract Penile fracture is an uncommon condition. Fracture of the penis is a tear in the tunica albuginea of the corpora cavernosa that may be associated with injury to the corpus spongiosum and urethra. We describe the case of a 51-year-old man who presented with acute penile pain, penile swelling, and hematuria after a blunt trauma during sexual intercourse. retrograde urethrography examination revealed extravasation from the distal penile urethra into the cavernous structure. In cases of penile fracture, retrograde urethrography can be used for definitive diagnosis.
Keywords: Penile fracture, urethral injury, imaging, retrograde urethrography
Introduction disfigurement, and blood in the urethral meatus urethrorrhagia. These symptoms had emerged 6 hours Fracture of the penis is a tear in the tunica albuginea earlier, and the patient was still able to void in small of the corpora cavernosa which may be associated amounts, with blood present in his urine. During the with injury to the corpus spongiosum and urethra.1 Diagnosis is usually clinical, and urethral injury should be suspected in the penile fracture, especially in those cases with bilateral cavernosal rupture.2
If there is blood in the meatus, hematuria, and difficulty in voiding, an associated urethral injury. Immediate retrograde urethrography considered if the symptoms of urethral injury are present.3
This paper aims to present a case of penile fracture with associated urethral injury, diagnosed by retrograde urethrography.
Case Report Figure 1 hematoma in the ventral penile shaft A male patient, aged 51, came to the emergency unit physical examination, a hematoma in the ventral complaining of the sudden loss of erection during sexual penile shaft, pain during palpation, and urethrorrhagia intercourse, penile swelling, hematuria, discoloration, were present [figure 1]. The patient’s history and a physical examination indicated a penile fracture. The patient’s retrograde urethrography revealed extravasation from the distal penile urethra into the Corresponding author: cavernous structure [figure 2] Iwan Purnomo Aji K.H. Ach. Faqih st, 01, Pangeranan, Bangkalan, East Java, 69115. Tel +62 856 4994 7296. email [email protected] Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 301
symptoms of urethral injury. A retrograde urethrography should promptly be requested for effective treatment planning and, if the injury is present, simultaneous urethral repair during surgery.9
Conclusions In the penile fracture associated with urethral injuries, retrograde urethrography is an option. With better outcomes and fewer long-term complications, early surgery is preferable to conservative management.
Funding Sources: Used during this study were sourced from personal funds.
Acknowledgments: The authors wish to thank dr. Figure 2 Urethral distal injury and rupture of Muchdor, Sp.B., FINACS as President of Semen Gresik corpus cavernosum in retrograde urethrography Hospital. Thank you to all staff who provide the medical Discussion record. We also thank the respondents of the study for their contribution. Penile fracture is a rare urological emergency. The tunica albuginea is a structure of great tensile strength Internal Conflict: All authors declare that they that can withstand rupture at pressures up to 1500 have no conflict of interest. mmHg. The tunica albuginea thins markedly during Ethical Clearance: Ethical approval has been erection, which when combined with abnormal bending obtained from the Ethical Commission of Health leads to excessive intracavernosal pressure and most Research. often a transverse laceration of the proximal shaft.4,5
Penile fracture is diagnosing based on the patient’s References history, clinical examination, and the classic triad: 1. Eke N. Fracture of the Penis. Br J Surg. audible “cracking” sound, followed by immediate 2002;89:555–65 swelling and pain.3 2. Dever DP, Saraf PG, Catanese RP. Penile fracture: operative management and cavernosography. Penile fracture is mostly caused by the bending of Urology. 1983;22:394–6. the erect penis either over the pubic bone or the perineum 3. Tsang T, Demby AM. Penile fracture with urethral of a sexual partner, during brutal masturbation, or injury. J Urol. 1992;147:466–8. penile kneading and snapping to make sudden swelling. A transverse 1 to 2 cm tunica tear, usually unilateral, 4. Jack GS, Garraway I, Reznichek R, Rajfer J. Current treatment options for penile fractures. Rev is present despite reports of tears in both corporeal Urol 2004;6:114‑20. bodies.6,7 5. Agarwal MM, Singh SK, Sharma DK, Ranjan Penile fracture diagnosis is mostly made clinically P, Kumar S, Chandramohan V, et al. Fracture of without the need for more diagnostic tools as the fracture the penis: A radiological or clinical diagnosis? site is obvious. Cavernosography is considered in A case series and literature review. Can J Urol complicated cases due to the inherent contrast reaction 2009;16:4568‑75 fibrosis from extravasated contrast medium, infection, 6. Asgari MA, Hosseini SY, Safarinejad MR, and priapism risk or only in deep dorsal vein rupture Samadzadeh B, Bardideh AR. Penile fractures: of the penis, which might be indistinguishable from evaluation, therapeutic approaches, and long-term cavernosal rupture.8 results. J Urol. 1996;155:148–9. 7. El-Taher AM, Aboul-Ella HA, Sayed MA, Gaafar Urethral bleeding and voiding incapacity are 302 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
AA. Management of penile fracture. J Trauma. fracture of the penis. Br J Urol. 1993;72:228–9. 2004;56:1138–40. 9. Agrawal SK, Morgan BE, Shafique M. Experience 8. Koga S, Santo Y, Arakaki Y, et al. Sonography in with penile fractures in Saudi Arabia. Br J Urol. 1991;67:644–6 DOI Number: 10.37506/ijphrd.v12i1.13866 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 303 Cyber-Pornography Addiction among Medical Students of Telangana
K.Hari Praveera1, M.Anudeep1, Syam Sundar Junapudi2 1Final year MBBS student, Government Medical College, Nizamabad, 2Associate professor, Department of community medicine, GMC, Suryapet
Abstract Introduction:- It is understood as an act of using cyber space to create, display, distribute, impart or publish pornography or obscene materials, especially materials depicting children engaged in sexual acts with adults. There are tons of materials which are available now at our fingertips with the advent of 4G network and smart phones. Almost 50% of the websites exhibit pornographic material on the internet today. Pornography is accessible to anyone and everyone. 9 out of 10 boys are exposed to some form of pornography before the age of 18 years whereas the average ratio is 6 out of 10 for girls. Objectives:-1. To identify the prevalence of risk of cyber-pornography addiction amongst medical students. 2.To identify the type of risk present among the students. Methodology:-This study was conducted with the help of a pre-designed, pre-tested web-based questionnaire based on Internet Sex Screening Test amongst the medical college students of Telangana.Duration of the study: 1st January 2019 to29th February 2019 (2 months). Results: - In the present study most of the study population (59.02%) was 3rd MBBS students, less study population from internees (4.39%). Males were 58.35% and females were 41.46%. Among Males 75 (36.58%) are under low risk, 45 (21.95%) are at risk, Among Females 82 (40%)are under low risk, 3 (1.46%)are at risk which was statistically significant.Conclusion:- It is concluded that majority of the males and females came under low risk category but males were more under vulnerable category. So males showed higher risk of addiction to pornography. Pornography is affecting the lives of the students. Recommendations:- Educating the masses about the detrimental effects of cyber pornography at the levels of individual, family, society and the nation .Compulsory sex education during high school i.e. during the formative years of an adolescent.
Key words: - Medical students, cyber pornography, adolescents, MBBS students.
Introduction the internet today. Pornography is accessible to anyone and everyone. 9 out of 10 boys are exposed to some form It is understood as an act of using cyber space to of pornography before the age of 18 years whereas the create, display, distribute, impart or publish pornography average ratio is 6 out of 10 for girls. On an average the or obscene materials, especially materials depicting 1st exposure is at 12 years of age for either sex. 88% children engaged in sexual acts with adults.[1] There are of porn scenes contain acts of physical aggression and tons of materials which are available now at our fingertips 49% contain verbal aggression. Due to such content it with the advent of 4G network and smart phones. Almost is found that it has an accessory role in negative social 50% of the websites exhibit pornographic material on issues like child abuse, violence against women, rape, inequality, relationships, family breakdown, youth crime, promiscuity and sexually transmitted diseases. [2] Corresponding Author A new study out of Indiana University and the University Syam Sundar Junapudi, of Hawaii at Manoa, states that: “As with all behavior, Associate professor, Department of community sexual aggression is caused by a confluence of factors medicine, GMC, Suryapet, Telangana. and many pornography consumers are not sexually Cell +919966673688, [email protected] aggressive. However, the accumulated data leaves little 304 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
doubt that, on the average, individuals who consume criteria:- non medical students and who are not willing pornography more frequently are more likely to hold to participate in the study. 205 medical students attitudes conducive to sexual aggression and engage in consented to take part.They were educated about the actual acts of sexual aggression than individuals who do research.The data collected was completely confidential not consume pornography or who consume pornography and the participants remained anonymous. The data was less frequently.”[3] According to India Times, India analyzed using MS EXCEL 2016. moved from 4th to 3rd position in the list of most porn Study Tool:-A web based ISST questionnaire was watching countries in the year 2017.[4] Incidentally, used.[6] India is in 4th position among countries with highest rape [5] crime. There maybe a relation between the two, due to The Internet Sex Screening test questionnaire the recent surge in the rape cases in India. consists of a total of 34 questions which can be classified as Cyber-pornography Addiction:- Addiction can be broadly defined as “compulsive, uncontrollable Internet related sexual behavior (1 to 25) Divided dependence on a substance, habit, or practice to such into the following subgroups a degree that cessation causes severe emotional, mental or psychological reactions”Though this term 1. Online sexual content, social context has been applied to cases involving intake of drugs, 2. Online sexual behavior similar criteria have been used to assess a number of problematic behaviors.One such is addiction to 3. Solitary sexual behavior pornography. Pornography Addiction as a Mental Health Disorder does not officially exist.Cyber-pornography 4. Online sexual spending addiction is clinically defined by using the criteria for 5. Internet in online sexual behavior other established addictions.It is a Self perceived or Self diagnosed condition.Pornography addiction is often General sexual compulsive behavior (26 to 34), The defined operationally by the frequency of pornography questionnaire provided online had the questions from 1 viewing and negative consequences.A research paper on to 25 only. They were to respond to them by answering as cyber pornography addiction among medical students of YES or NO, Questions 26 to 34 are abbreviated versions western rural Maharashtra in 2017 showed that majority of Sexual Addiction Screening test. They may be used of the males come under the vulnerable category to review general sexual addiction, not specifically for whereas females belong to the low risk group and cyber sex so they were not included. males have higher addiction rates based on the internet The Internet sex screening questionnaire: sex screening test[1]No such research has been done in Telangana before. 1. I have some sexual sites bookmarked.
Aims and Objectives:- 1.To identify the prevalence 2. I spend more than 5 hours per week using my of risk of cyber-pornography addiction amongst medical computer/smartphone for sexual pursuits. students. 2.To identify the type of risk present among the students. 3. I have joined sexual sites to gain access to online sexual material. Materials and Method 4. I have purchased sexual products online. This study was conducted with the help of a pre- designed, pre-tested web-based questionnaire based on 5. I have searched for sexual material through an Internet Sex Screening Test amongst the medical college Internet search tool. students of Telangana.Duration of the study: 1st January 6. I have spent more money for online sexual 2019 to 29th February 2019 (2 months).Inclusion material than I planned. Criteria: All the medical students who consented to participate in the research were included. Exclusion 7. Internet sex has sometimes interfered with my Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 305 certain aspects of my life. accomplishing something. (e.g., finishing a project, stressful day, etc.) 8. I have participated in sexually related chats. 19. When I am unable to access sexual information 9. I have a sexualized username or nickname that I online, I feel anxious, angry, or disappointed. use on the Internet. 20. I have increased the risks I take online (give out 10. I have masturbated while on the Internet. name and phone number, meet people offline, etc.) 11. I have accessed sexual sites from other computers 21. I have punished myself when I use the Internet besides my home. for sexual purposes (e.g., time-out from computer, 12. No one knows I use my computer/smartphone cancel Internet subscription, etc.) for sexual purposes. 22. I have met face to face with someone I met 13. I have tried to hide what is on my computer or online for romantic purposes. monitor so others cannot see it. 23. I use sexual humor and innuendo with others 14. I have stayed up after midnight to access sexual while online. material online. 24. I have run across illegal sexual material while 15. I use the Internet to experiment with different on the Internet. aspects of sexuality (e.g., bondage, homosexuality, anal 25. I believe I am an Internet sex addict. sex, etc.) ISST risk scoring 16. I have my own website which contains some sexual material. RISK SCORE 17. I have made promises to myself to stop using the LOW 1-8 Internet for sexual purposes. VULNERABLE 9-18 18. I sometimes use cybersex as a reward for HIGH 19-25
Results Table 1:- Distribution of study population based on year/batch and sex
DISTRIBUTION OF STUDY POPULATION BASED ON YEAR/BATCH AND SEX
Year Males Females Total (N=205)
1st MBBS 28 (13.65%) 5 (2.43%) 33 (16.09%)
2nd MBBS 16 (7.8%) 12 (5.85%) 28 (13.65%)
3rd MBBS 58 (28.29%) 63 (30.73%) 121 (59.02%)
4th MBBS 10 (4.87%) 4 (1.95%) 14 (6.82%)
INTERNSHIP 8 (3.90%) 1 (0.48%) 9 (4.39)%
TOTAL 120 (58.35%) 85 (41.46%) 205 (100%) 306 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
In the present study most of the study population (59.02%) was 3rd MBBS students, less study population from internees (4.39%). Males were 58.35% and females were 41.46%.
Table 2:- Age and Sex wise Distribution of study population
AGE AND SEX WISE DISTRUBUTION OF STUDY POPULATION
Age Male Female Total (N=205)
17-19 29 (14.14%) 11 (5.36%) 40 (19.51%)
20-22 77 (37.56%) 70 (34.14%) 147 (71.70%)
23-25 14 (6.82%) 4 (1.95%) 18 (8.78%)
TOTAL 120 (58.53%) 85 (41.46%) 205 (100%)
In the present study most of the study population were in the age group of 20-22.
Table 3:- Distribution of study population depending on the type of risk
PREVALENCE OF RISK AMONG MALES AND FEMALES
TYPE OF RISK MALES FEMALES TOTAL
Low Risk 75 (36.58%) 82 (40%) 157(76.58%)
At Risk 45 (21.95%) 3 (1.46%) 48 (23.41%)
TOTAL 120 (58.35%) 85 (41.46%) 205 (100%)
Chi- Square = 30.1535 CI= 95% P=less than 0.01
Among Males 75 (36.58%) are under low risk, 45 (21.95%) are at risk, Among Females 82 (40%)are under low risk, 3 (1.46%)are at risk which was statistically significant.
Table 4:- Distribution of study population depending on the type of risk and year of study. PREVALENCE AMONG 1ST MBBS
Males Females Chi- Square P value
At risk 4 0 0.87 (NS) 0.024 Low risk 24 5
PREVALENCE AMONG 2ND MBBS
Males Females Chi-Square P value
At risk 6 0 0.05 3.05 Low risk 10 12
PREVALENCE AMONG 3RD MBBS Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 307
Cont... Table 4:- Distribution of study population depending on the type of risk and year of study.
Males Females Chi-Square P value
At risk 29 2 <0.01 32.33 Low risk 29 61
PREVALENCE AMONG 4TH MBBS
Males Females Chi-Square P value 0.60 At risk 3 0 0.26 (NS) Low risk 7 4
PREVALENCE AMONG INTERNS
Males Females Chi-Square P value 0.66 At risk 3 0 0.27 (NS) Low risk 5 1
In this study risk was more prevalent in 3rd MBBS students fallowed by 2nd MBBS students, less prevalent in internees
Table5:-Responses to various questions
Males Females Spent more than 5 hours per week on internet searching for sexual 25 3 content Searched for sexual content online 56 26
Internet sex interferred with certain aspects of life 36 3
Participated in sexually related chats 9 17
Masturbated while on the internet 75 10
No one knows i use the computer/smartphone for sexual purposes 51 8
Tried to hide what is on the computer/smartphone 69 19
Stayed up after midnight to access sexual material online 65 8
Used the internet to experiment with different aspects of sexuality 31 6
Made promises to stop using internet for sexual purposes 66 20
Use cybersex as a reward for accomplishing something 44 3
Feel anxious or sad when unable to access sexual content online 48 5
Believe that they are an Internet sex addict 38 2
308 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Discussion the internet -86.From the questions which have been answered the most , we can find a relation among them In the study conducted, 205 medical students which is similar to that seen in an addiction cycle. participated by filling the web based questionnaire. The data collected was completely unanimous and AddictiveNature:-We find that there are triggers confidential. 76.58 % (157) of the volunteers are in low present which are met by browsing the net for sexual risk category, 22.92 % (47) in vulnerable category and material.Some stay up after midnight because their 0.48% (1) in high risk category. Among Boys 62.5% (75) thoughts are so irresistible.After that they act out by are of low risk, 36.66% (44) are vulnerable, and 0.83% masturbation which activates the reward center.They try (1) are in high risk. Among Girls 96.47% (82) are of low to hide what is on their gadgets due to the guilt.They risk, 3.52% (3) are vulnerable and 0% are in high risk. make promises with themselves to stop using the internet The only limitation of the study is that it is not possible for sexual purposes.Then again they end up yielding to ascertain if the volunteer was completely honest while to their desires.Thus, the addictive nature of cyber- providing the information.In the study it was found that pornography can be noticed.According to American the most answered questions were I have searched for society of Addiction Medicine, some psychological sexual content online -82,I have masturbated while and behavioral changes characteristic of addiction brain on the internet -85, I have tried to hide what is on my changes includes addictive cravings, impulsiveness, computer/smartphone so others cannot see it 88, I have weakened executive function, de sensitization and stayed up after midnight to access sexual material online dysphoria can be seen in individuals who consume more 73,I have made promises with myself to stop using amount of pornography.
COMPARISION OF PREVALENCE
STUDY IN WESTERN RURAL AMONG MEDICAL STUDENTS THIS STUDY MAHARASHTRA1
TOTAL 23.41% 43%
MALES 37.5% 79%
FEMALES 3.52% 27%
Conclusion effects of cyber pornography at the levels of individual, family, society and the nation. ● It is concluded that majority of the males and females came under low risk category but males were ● Compulsory sex education during high school more under vulnerable category. i.e. during the formative years of an adolescent.
● So males showed higher risk of addiction to ● Active measures by the government through pornography. banning of pornographic sites which host illegal and harmful aggressive content from the internet. ● Pornography is affecting the lives of the students. Ethical Clearance- Taken from institutional ethical committee, GMC, Nizamabad, reference no ECR/951/ Recommendations Inst/TG/2017 ● Educating the masses about the detrimental Source of Funding- Self Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 309
Conflict of Interest - Nil sexual aggression in general population studies. Journal of Communication. 2016 Feb 1;66(1):183- References 205. 1. PANDEY AK, KUNKULOL RR. CYBER 4. Prakash A. Role of Prohibitory Legislation in PORNOGRAPHY ADDICTION AMONGST Preventing Online Sexual Abuse of Children: A MEDICAL STUDENTS OF WESTERN RURAL Critical Socio-Legal Analysis. Unitedworld Law MAHARASHTRA. Int J Clin and Biomed Res. Journal. 2018 Dec 18;2:2457-0427. 2017;3(2):10-4. 5. Kumari PG, Abhishek M, Anjali P, Kumar DS. 2. Verma A. Cyber pornography in India and its Wake up call to halt the evolving epidemic of implication on cyber cafe operators. Computer Law sexual offence in India: Urgent need to find out the & Security Review. 2012 Feb 1;28(1):69-76. solutions. 3. Wright PJ, Tokunaga RS, Kraus A. A meta-analysis 6. Delmonico DL. Internet Sex Screening Test. 1997. of pornography consumption and actual acts of 310 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13867 Impact of Educational Program for Adolescents and Young Adults with Sickle Cell diseases on their knowledge, Perception, and Self-Care
KhadigaAbdElgiedGomea Hassan1, Shereen Ahmed AhmedQalawa2 1Lecturer of Pediatric Nursing, Faculty of Nursing, Shaqra& Port-said university, KSA & Egypt, 2Associate Professor of Medical-Surgical Nursing, Nursing College , Qassim university , KSA, 2Professor of Medical-Surgical Nursing, Faculty of Nursing, Port-said university, & Egypt
Abstract Self-Management Program(SMP) has a significant positive effect on self-care of a patient with chronic disease. Improving self-care is the most essential stepsto control several complications. Aim: to assessthe influence of applying educational program onknowledge, perception, and self-care of adolescent and early adulthood individual suffering from Sickle Cell Diseases ( SCD). Design of Quasi-experiment was implemented in this study. The current research study was accomplished in the Center of Genetic Blood DiseasesinQatif Central Hospital in the East Area of Saudi Arabian. Subjects: Apurposivesample composed of 82 early adulthood individual suffering from SCD. Their ages were between 14-20years. Tools: Interview sheet, itincluded three parts; socio-demographic data,SCDassessment sheetandtheknowledge assessment sheet. Tool for assessment of self-care management is The Adolescent and young adult Independence Checklist (AAC- SCD). Results:Theresult of the current study mentioned thataround 15 % of patients were receiving special educational services, and more than 80% reported that the SCD interfered with their school achievement. Also, most of them (79.3%) had no wish for complementing theSCD treatment before the program while after intervention two-third of themmentioned that they will completeSCD treatment.The difference was statistical significant regarding patients self- care managementprior and after three months from the program, P< 0.01.Conclusion:Results support the necessity for Self-Management Program to improve self- care activities in adolescent and early adulthood individual suffering fromSCD.Recommendations: there are an obvious needsto implement those educational programs in ordered to increase awareness and improve self-careamongearly adulthood suffering fromSCD.
Keywords: Program, Sickle Cell Disease(SCD), Adolescent, young adults, perception, self care
Introduction of sickle cell disease (SCD), the most common type is sickle cell anemia that refers to hemoglobin SS disease, The term sickle cell disease (SCD) refers to more and the other type is sickle hemoglobin C disease, also than one disease. SCD is a genetic disorder of the blood known as hemoglobin SC disease3 affecting red blood cells which become rigidand unable to properly deliver oxygen to the body. It is characterized The affected red blood cells in the individual with bya present of abnormal hemoglobin1. The clinical SCD which composed hemoglobin S are formed like a features are varied and can includeofvaso-occlusive, banana in shape, this shape makes obstruction on blood hematological and infectious crises. Then the pain and vessels, leading to a recurrent crisis of severe pain.2 fatal health problem may occur.2There are many types Also,the influenced cell gets to be difficult and incapable to supply oxygen to the body parts causing ischemia and Cooresponding Autor: harm of the multi-body organs. The breakdown of the KhadigaAbdElgiedGomea Hassan red blood cell effortlessly down causing anemia.4 Sickle E.mail: [email protected] cell characteristic (SCT) is an acquired state in which Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 311 both typical hemoglobin and sickle hemoglobin are period. As a result, the issue of self-care is an essential delivered within the RBCs. SCT isn’t sorting of SCD. part of care in the management of teenagers with an Individuals with SCT are generally healthy.5Individuals SCD, in addition to medical and nursing care, to realize who have traits of SC generally have no disability in healthy lifestyle.13 their health status and not eversuffer from SCD. These Saudi Arabia got to be a developing Kingdom individuals might have a child carry SCT or suffering with a huge alter happened within the way of life of from SCD.6 the people among urbanization, particularly over the The harshnessof types ofthis disease differ, it may preceding three decennium. So the developing of a self- asymptomatic or it may be categorized betweenmild care health program for adolescent and early adulthood and to severe states thatneed hospitalization where the individualsuffering fromlong-lastingillnessesis very treatments of the symptoms arefound.7 vital to move forward their healthy lifestyle and empower them for self-care.14 The appropriate setting to supply progressing wellbeing care of people with sickle cell infection Significant of the study surge may be an extraordinary center with a proficient The prevalence of sickle-cell trait ranges between staff.8whichprovides health care to people with sickle cell 10% and forty percent throughtropical Africa and disease, not as it were within the case of emergencies but declines to between one percent and two percent on too within the free case. To begin with, the people ought the North African coast and less than 1% in South to be explored at birth as portion of a infant evaluation Africa. This dispersion reflects the truth that sickle- screening program, within the essential wellbeing cell characteristic confers a survival advantage against care center and alluded to a uncommon healing center malaria hich choice weight due to malaria has resulted in for advance examination on the off chance that SCD high frequencies of the mutant gene, particularly within affirmed, viable communication between the essential the regions of high malaria transmission. Although a health care center and the hospital are basic for suitable single unusual gene may protect against malaria, care.9 the legacy of two unusual genes leads to SCD and More than 300,000 infant children are born in the confers no such protection, and malaria is most cause world with SCD primarily from a low and middle class, of morbidity and death inafrican individuals affected most of them from Africa. Over 70,000 persons in the from SCD 27. United State of America have sickle cell disease4,10. Adolescence is characterized as the period of life that SCD is present throughout Saudi Arabia; particularly starts with the appearance of secondary sex characteristics common in the eastern and southern provinces: Qatif and closes with the cessation of development and (east area) seventeen percent , Gizan (southarea ), accomplishment of emotional development. Youth could around ten percent Ula (Northare) around eight percent be a surge towards independence, which interferes and Mecca (west area ) areound 3 percent .11 with chronic illness.Chronic illness during adolescence Five percent of the individuals are suffering from especially SCD runs counter to developmental needs. SCD around the world. This is in realtion to that SCD is Nurses should support sick people to adjust with body the commonest public health disability with no terminal image concerns.They must develop an awareness of the curative care . An effective health program should be teenagers toward particular fears of forced dependence, done for these persons in relation to investigations, rejection by society and loss of adaptation, especially management, education (school performance) and with peer group.16-19 Many adolescent and early marriage.12An adolescent period is a more basic adulthood individuals who suffering from with long- period for life stages; youth includes a organize of a lastingsickness or developingincapacities are assisted development spurt meaning faster in physical growth, at home through home health agencies and community the improvement of secondary sexual characteristics, and agencies which work together to meet the physical and speeding up in cognitive and psychosocial development. psychological needs of the patient. The nurses have So much consideration ought to be focused in such a an chief role in implementing a health program for 312 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
adolescents.20- - Positive hepatitis B and or C.
. Subjects: A purposivesample composed of 82 Tools: early adulthood individual suffering from SCD. I. Interviewing questionnaire sheetwas designed Their ages were between 14-20 years and utilized by the researcher after reviewing of literature Aim of the study: is comprised of three parts:
This study aimed toto assess the influence of applying Part I: socio-demographic data of the studied educational program on knowledge, perception, and subjects and their fathers and mothers , such as age, sex, self-care of adolescent and early adulthood individual patients order, and level of schooling,job of their fathers suffering from SCD. and mothers.
Research hypothesis: Part II: SCDdata assessment sheet was developed by the researcher to assessthe Adolescent and early adulthood individual suffering health status of studied adolescents related to sickle from SCDwho receive self-care program able to perform cell anemia such as the impact of illnesses on a way of basic daily care effectively. life of teenagers, students beliefs and attitudes towards 28,29 I. Methods sickle cell anemia.
Research Design:Quasi-experiment was Part II:Patients’ knowledge questionnaire implemented in this study. It was created by the researcher after checking on the Setting:24Therefore; there is an urgent need for related literature in order to assess the patient’s level of developing self-care programs for adolescents with knowledge before/ after the self-care programregarding SCD. meaning , management, and complications of SCD.
the current research study was accomplished in Part III:The Adolescent Autonomy Checklist 31,32 the Center of Genetic Blood Diseases in Qatif Central (AAC-SCD). Hospital in the East Area of Saudi Arabian Tool for assessment of self-care management, ( Sample : A purposive sample of 82 patients ( basic daily living activities) adolescent and early adulthood) with sickle cell disease AAC–SCD is a self -report checklist consists of inclusion Criteria: kitchen, nourishment, washing, housework, disaster, individualactivities, medication management, - age between 14-20 yearsat theonset of the study. sexual change, money managing, leisure time, occupationalactivities, and living arrangement; it filled - Diagnosed by sickle cell disease asHaemoglobin in approximately twenty minutes. The AAC–SCD was SS ( Hbss) or beta-zero thalassemia genotype. integrated into standard care for adolescent and early - Ableto write consent. adulthood indviduals cured in the Sickle Cell Clinic beginning at age 13 - Haemoglobin concentricity was more than 4.5 g/dL at the stablestatus and atthe time of the study. Scoring system:
- Have a desire to include in this study. The levels of patient knowledge of SCD
Exclusion Criteria: It was developing by the researcher following revising the correlated texts to evaluate the patient’s - Less than 14 years or more than 20 years. levels of knowledge before and after carrying out - Positive HIV. the study in relation to definition, management, and complications of SCD, 23,25.Reliability test was done Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 313
whileCronbach’s Alpha equals 0.70 and anonymity of the patients were assured during the coding of the data. Patients and parents of adolescent Everytruesolutiontook 1whereas the false one were assured that the data were not being reused in took 0.33 another research without their acceptance The overall score was categorized as follows into · A pilot study was carried out on8 of adolescents two groups: and early adulthoodwith SCD to clarify the validity § < 60% total scoreswerecategorized as the un- of the questionnaires and to test the feasibility, clarity satisfactory level of knowledge. and objectivity of the tools. The test included within the pilot study was avoided from the study test, § ≥ 60% of the total scoreswerecategorized as a and the vital adjustments were done appropriately. satisfactory level of knowledge. The test was separated into four bunches, each gather has twenty or twenty-two patients. The transitional program Procedure was impelemented two days till week for each grop. The · Formal approval: An pre/posttest was applied to evaluate the outcomes of official authorization was allowed from immediately after implementing the program. a regulatory staff of the Center · The average time needed to complete all tools of Genetic Blood Diseases in Qatif ranged from 35-45 minfor pretest and posttest for each Central Hospital to get their authorization to conduct patient. the study after clarifying the reason for the study. · The intervention took place between 25/March · The study tools were created by – 13/June2017 the analyst after checking on the relevant literature. The apparatuses were tested for the validity of their · The collected data were analyzed to obtain contents by a panel of five experts specialized in Pediatric the results of the effect of the self-care program on and Medical-Surgical Nursing to ascertain relevance adolescent and early adulthood patients. and completeness. These experts assessed the tools for clarity, relevance, comprehensiveness and applicability. Statistical Analysis The suggestions given by experts were considered and Information was coded and changed into the tools were altered. The final tools took its shape after an extraordinarily planned format appropriate for alterations based on the opinion of the guide. computer feeding. All entered information was · The reliability of the SCD assessment sheet and confirmed for any mistakes. Patients’ knowledge sheets were measured using a test Information wasanalyzed utilizing statistical and retest method and Pearson correlation coefficient package for social sciences (SPSS) version 20 windows formula to ascertain relevance and consistency of the and was displayed in tables.Chi-square test (c2). For tools to measure their items. The values were r = 0.70 comparison between means of two groups of parametric and 0.85 respectively information of free samples, student t-test was utilized. · Ethical considerations and human rights: A Importance was received at p< 0.05 for translation of written consents weretook from parents of adolescent resultsof tests of significance. and patients who were willing to contribute in the research. Before conducting the study confidentiality 314 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
II. Results
Table (1): Negative effects of SCD on adolescents and early adulthood with SCD.
(n =82) Variable No %
1-Feel weakness: Yes 69 84.2 No 13 15.8 2- Inability to do thing Yes 66 80.5 No 16 19.5 No
3- Bad emotional response: Yes 67 81.7 No 15 18.3
4- Social relation: Yes 65 79.3 N0 17 20.7
5- No desire to complete treatment: Yes 65 79.3 No 17 20.7
Table (1) shows thataccording to the effect of sickle cell disease on the health status of adolescents and early adulthood withSCD,the most (84.2%) of themsuffered from weak feelingand54.12 %unable to do a thing. 80.5% ofstudied patientshad bad emotional response toward disease. Also, the most (79.3%) of the studied patients had no desire to complete treatment.
Table (2): Comparison between the adolescents and early adulthood knowledge towards sickle cell disease before and after the program.
Before (n =82) After (n= 82) Knowledge No % No %
Satisfactory 4 4.9 82 100
Unsatisfactory 78 95.1 0 0.00
Test c2 (P-value) 6.97 (0.02*) *Statistically Significant
Table (2) shows that 95.1% of theadolescents and early adulthood with SCD had unsatisfactory knowledge about SCD before carried out of the program. While after thecarried out the program the 100% of theadolescents and early adulthood withSCDhad a good knowledge about SCD. The difference was statistical significant,P-value = 0.02. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 315
Table (3): Comparison between the adolescents and early adulthoodwithSCD toward self-care before and after the program.
Before After (n =82) (n= 82) Self-care during c2 P- value
No % No %
Free from pain and fever and able to perform self -care: Yes 4 4.9 69 84.2 16.16 0.001 No(dependent on caregiver) 79 95.1 13 15.8 *
* Statistically Significant
Table (3) shows that regarding the self-care of adolescents and early adulthood withSCDbefore and aftercarried outthe program, most (84.2%) of adolescents and early adulthood withSCDperform their self- care when they are free from pain and fever. While more than a quarter (15.8%) of them dependent on their parents.The difference was statistical significant, P-value <0.001.
Figure (1): Factors influencing the ability of self-care of adolescents and early adulthood withSCDbefore and after the program
. Figure (1) shows that more than (70%) ofadolescents and early adulthood withSCDreported that parents support is the most factors enhancing them to self-care management.
Discussion avoiding emergencies, calming side effects and avoiding complications.18 Sickle cell disease (SCD) can mention as a genetic defects recognized by defecting in Adolescence stage has been recognized as the first hemoglobin atoms, falling flat of the obstacle for health promotion and adloscesnsusceptible bloodstream decreasing oxygen sufficiency of red blood to manyunfavorable behaviours.24Also,adolescents and cells, harming of organ, and occurring ofcomplications.17 early adulthood with SCD may facing many stresses Sickle cell disease affects millions of people worldwide. of the developmental stage and disease process. As a result, treatment for SCD is ordinarily pointed at Also,theyexperiencing some particularworriesconcerned 316 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
withSCD, as problems associated with images of their According to the effect of sickle cell disease on bodies, managing pains and anxietyto bedependenent of the health status of the studied patients, the most of the analgesic.10 studied adolescents suffered from weak feeling and had bad emotional response towards disease, unable to do Self-management, social assistance, socio-economic the thing. From the point of view of the researcher, these state, and self-care have been recognized as serious may due to the effect of the disease. These results go in concepts correlated with the management of SCD and all one way with 6who found that adolescents and young chronic disorder. Regarding scientific research,self-care children with SCD complained from sad feeling and affects positively in the prognosis of the disease and the easily fatigued. disease complications affect in it.13 In addition, more than half of the studied patients had Adolescents and children with SCD and their parents no desire to complete treatment. From the point of view scored significantly lower on several health-related of the researcher, these may due to half of the studied quality of life domains including; general physical, adolescents suffered froma bad emotional response motor and independent daily functioning.8 towards disease. This resultscorresponding with 26who In Saudi culture, several factors may explain the found that most adolescents with sickle cell anemia had process of psychological coping among adolescents with no desire to complete treatment. SCD. First, the extended family pattern inSaudi Arabia; Regarding the knowledge towards sickle cell family provide individuals suffering from anxiety the disease, before, and after the implementation of the presence of ‘‘safe persons’’ around them and hide active program the majority of the studied patients had symptoms of anxiety, maintaining them functional in a unsatisfactory knowledge before the implementation of compensatory behavior.9 the program. After the implementation of the program,all In the present study, the studied patients with SCD of the studied patients had good knowledge about sickle 24 aged between 14 to 20 years with a mean of 16.9 ± 17 cell disease. These results go on one way with who years. From the point of view of the researcher, these indicated that the knowledge of patients was not satisfied may due to characteristics of the study sample. in the pretest, and it became good in the post-test.
Studied patients with SCD, have a medium socio- The present study found that parents support is an demographic profile in terms of parental educational important assistant to encourage and improve self-care status and family income. From the point of view of the for adolescent female students with SCD. This finding 16 researcher, these may due to the most of fathers of the corresponding with illustrated that social aideshelp studied patients were employee, which means they had individuals with SCD to share self-care planning. the only salary. IV. Conclusion As regards, socio-demographic characteristics of Study findings supplement preceding studies and parents of the studied patients, half of both parents of participate in an improvedand encourage the role of self- them had secondary education. Also, less than half of care for an teenages and young adults with SCD.teenages the mothers werea housewife.The majority of studied and young adults with SCDexperienceing health-related patients had bad school achievement. This results improve quality of life containingbodily functions and corresponding with 15 whofoundthat absenteeism may be painoccuranceparalleled to their contrastindividulas. To the largest obstacle to school success for some children improve health status the assessments in adolescents with sickle cell disease. Also8 stated that children and with SCD facilitate nurse-patient communication, point adolescents may be absent a lot due to clinic visits, pain to areas where patients may experience serious problems crises or other health problems which leads to bad school during this transitory phase, using as diagnostic tools for achievement4.Suggested that children and adolescents follow–up care, and assessing the efficiency of different should encourage participating inan extracurricular treatment technique. activity in which they should excel. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 317
V. Recommendation perspectives from a Nigerian setting. Globalization and health, 6(1), 2. According to results of current study the following 3. Anie K. A.; Egunjobi F. E. and Akinyanju O.O. wasrecommended: : Psychosocial impact of sickle cell disorder: · A well organized and structured educational perspectives from a Nigerian setting . Globalization program about the importance of self-care of life of and Health. 2010,6:2 doi:10. 1186 1744-8603-6-2. sickle cell patients should be established for patients and 4. Brandow Amanda, BrousseauDvid, Pajewski their family. Nicholas, Panepinto Julie. 2010.Vaso-Occlusive Painful Events in Sickle Cell Disease: Impact on · Health care providers should take time to Child Well-Being. Pediatr Blood Cancer. 2010 explain in-depth the management of sickle cell diseases Jan;54(1):92-7. for patients and their family. 5. Ahmadi, M. Jahani,S.Poormansouri,S.Shariati, A &Tabesh, H. 2015.The Effectiveness of self- · The mass media need to play an important role management program on quality of life in patients in health education for sickle cell anemic patients. with sickle cell disease. Iran J PedHematolOncol. · A well organized and structured educational 2015; 5(1): 18–26. program about health-related quality of life of sickle 6. Dampier Carlton , Lieff Susan, LeBeau Petra, cell patients should be established for patients and their Rhee Seungshin, McMurray Marsha, Rogers Zora, family Smith-Whitley Kim, Wang Winfred. 2010. Health- related quality of life in children with sickle cell VI. Acknowledgement disease: A report from the Comprehensive Sickle Cell Centers Clinical Trial Consortium. Pediatr Our appreciation and gratitude and gratitude to Blood Cancer; 55(3):485-94. participants who agreed to participate in the study and 7. Gray , Gibbons. Living with sickle cell anemia. gave us the opportunity to accomplish the study. 2013. US.Departement of Health & Human services. Conflict of Interest Statement 8. Haavet, O., Straand, J., Hjortdahi, p. &Saugstant, There are No conflicts of interest D. Do Negative Life Experiences Predict the Health – Seeking Behavior of Adolescents? A Study of Funding information 15 and 15 Years Old Students in Oslo, Norway. There are No funding budget from any institution Journal of Adolescents Health, 2005 37, pp 128- 134. and this research fund are done from researches 9. Hanberger Lena, LudvigssonLudvigsson, Nordfeldt Ethical Clearance: An official authorization was Sam. Health-related quality of life in intensively allowed from a regulatorystaff of the Center of treated young patients with type1diabetes. Pediatr Genetic Blood Diseases in Qatif Central Hospital at Diabetes. 2009 Sep;10(6):374-81. King dom Saudi Arabia as a responsible committee 10. Jenerette C, Brewer C, Edwards L, Mishel M, in this institution, to get their authorization to conduct Gil K. 2014. An intervention to decrease stigma the study after clarifying the reason for the study. in young adults with sickle cell disease. Western Journal of Nursing Reearch;36:599–619. [PubMed] References 11. Regina A. Abel, Esther Cho, Kelley R. Chadwick- 1. Amr, Amin TarekTawfik, Ahmed Omar Al- Mansker, Natalia D’Souza, Ashley J. Housten, and Omair. 2011. Health related quality of life among Allison A. 2015.Transition Needs of Adolescents adolescents with sickle cell disease in Saudi With Sickle Cell Disease.Transition Needs of Arabia.Afr Med J. 011; 8: 10. Published online Adolescents With Sickle Cell Disease.Am J 2011 February 15. OccupTher. 2015 Mar-Apr; 69(2): 6902350030p1– 2. Anie, K. A., Egunjobi, F. E., &Akinyanju, O. 6902350030p5. 2010. Psychosocial impact of sickle cell disorder: 12. KulkarniAbhava, Cochrane Douglas, McNeely 318 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
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Kirtimayee Soumyadarshinee1 Comparative health policy analysis between Patient and Client Safety Strategy (PCSS) of Finland, 2017 and National Patient Safety Implementation Framework (NPSIF) of India, 2018
Abstract In health care setting, damage can be triggered by series of faults or adverse events. The health organizations and social welfare services, are absolutely liable for quality health care and patient safety. The objective of patient care should complete abstinence of patients from any unessential or potential harm. The aim of the essay is to critically compare the national policies of two countries, Finland and India on ‘’Patient safety’’. Also, to examine and compare the relevant actors and stakeholders, including their interests and power; the pertinent factors that lead to the policy formation and the process by which the policy was implemented and monitored in both countries which are so diverse from each other; India being developing and Finland, developed. This paper also discusses the individual analysis of both countries, following a brief comparison of similarities and dissimilarities between policies of a developing and a developed country. After critically analyzing policies of the countries stark different from each other, the major dissimilarity noticed was the gap between the developed and the developing country and the sensitivity of the problem perceived which is described in detail further in the paper.
Keywords: policy analysis, health policy triangle, Indian policy system
Introduction the statistics, in developed countries as many as 1 in 10 patients is harmed while receiving hospital care. It is Patient safety is a fundamental element of health also estimated that globally of the 421 million patients care. It is being increasingly recognized as an issue of hospitalized annually, 42.7 million patients suffer from global importance, and a critical dimension of Universal adverse events cause of lack of patient safety. 2 To Health Coverage (UHC). The objective of patient overcome this situation, India launched its National care should complete abstinence of patients from any Patient Safety Implementation Framework(NPSIF) in 1 unessential or potential harm. According to WHO, of the year 2018. Similarly, Finland Patient and Client every 100 hospitalized patients at any given time, 7 in Safety Strategy(PCSS) was launched by the Finnish developed and 10 in developing countries will acquire government in the year 2017. healthcare-associated infections(HAI). According to The comparative essay begins, giving a brief idea of the framework used for the comparison of two Corresponding Author: national policies, followed by individual analysis of the Dr. Kirtimayee Soumyadarshinee developed and then the developing countries, ending Qualification- BDS (Bachelor of Dental Surgery) with a comparative study of the both. India and Finland MPH (Master of Public Health), Global Health were decided to be discussed upon since the basic idea Contact: +917978902914, +917539063828 was to highlight the differences of the same health issue Email: [email protected] between a developed and a developing country and ponder on how problems for one country goes unnoticed 320 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
or is not even of relevance to another country. updated the Patient Safety Strategy into the Patient and Client Safety Strategy (PCSS) in the year 2017, to Theory ensure services provided to the patients are safe and to Policy analysis is a set of complex, intertwining encourage maximum participation from patient/clients, procedures. From the different frameworks for analyzing and their family members. The aim of the policy is to policies, the one used in this essay is ‘’The Health Policy contribute to the development of Finnish health care Triangle’’ 3 which allows the retrospective analysis of the and social welfare services towards a harmonized safety 6 contextual factors, the process by which the policy was culture and to promote it in practice. formulated, implemented and evaluated, the objectives Actors of the policy and the actors. It presents a simplified approach to a complex set of interrelationships. 4 Ministry of Social Affairs and Health implemented the PCSS in collaboration with various establishments Actors are individuals, groups or organizations in the governmental units like the regional government involved in policy-making or who get affected once officials, Patient Safety Association and many other the policy is implemented. Context refers to universal ‘’actors’’ in the field which includes, health service factors which may have an effect on health policy. These providers like the doctors, nurses, etc; and most include situational, structural, cultural factors. Content importantly patients/clients and their family members. and process form the base of the triangle of health All key stakeholders use considerable influence on the policy analysis. Content details the issues addressed in policy process. Ministry of Social Affairs and Health, the policy. It comprises of the normative and cognitive Finnish health care and social welfare and the regional assumptions of the society. The process is a crucial step government form the intangible resources possessing in policy analysis. the maximum power and legitimacy in the policy issue Problem identification explains the agenda which play a pivotal and supportive role in articulating 6 setting. The second step is formulation, followed by the policy process. implementation, which is often the most neglected. Agenda setting/Problem Identification However, it is the most important step of policy making because if policies are diverted at the implementation, The increasing tendency towards outpatient hospital the policy outcomes will be distorted. Policy evaluation care with a shortage of manpower and rapid employee and monitoring is the ending procedure of the policy turnover leads to the overburdening of the work resulting process that deals with the post effects of policy in professional misconducts and assault. 7 Patient and implementation.3 client safety is a part of public service promise. The regional government, social welfare, and health care Patient and Client Safety Strategy (PCSS), (2017- reforms provide new opportunities for strengthening 2021) safety culture that promotes patient and client safety,
Finland belongs to countries that enjoy an highly that forms the Leichter’s (1979) structural and cultural 3 developed coordination for the furnishing of healthcare context of the policy. These were the unique focusing services. However, patient safety was unsuccessful to events that lead to the agenda setting and the problem gather ample awareness until recently. 5 Patient safety identification of the policy. Again, according to The was first introduced in Finnish legislation in the year Hall legitimacy, feasibility and support model; the issue 2010 by the Ministry of Social Affairs and Health. The was highly legitimate since promoting patient and client current theme of client safety emerged when the criteria safety is part of the responsibility for providing social for long-term inpatient care were made specifically welfare and health care, less feasible accounting the 3, 6 so that the older population avails inpatient care with constraints among the service providers and the policy patient safety justifications. Unfortunately, the policy gathered complete support from all important agencies was open to various interpretations and amendments. and stakeholders to successfully set in the agenda. Later, The Ministry of Social Affairs and Health Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 321
Policy Formulation. are implemented according to the statistics gathered on patient safety incidents. The organization has specific The Ministry of Social Affairs and Health is regulations on reporting and dealing with feedback. the crucial governmental department involved in Open discussions are organized by supervisors to formulating the policy. It involved other stakeholders discuss without blaming and are used for risk assessment such as regional government officials and health care promoting learning. The principle of no-blame and service providers in the formulation aiming towards the transparency is an essential part of the promotion of cohesive safety culture of patients. The essential contents patient and client safety, but immediate interventions of the policy are management, responsibilities, safety are taken for service providers that put patient safety at culture and legal provisions. Patients and their relatives stake. 6 are dynamically integrated in increasing excellence and wellbeing. The political context being the ministry and National Patient Safety Implementation the governmental agencies included in the actors, help Framework (NPSIF), (2018-2025) in the communication of the policy to the lower strata. Introduction Policy Implementation A multitude of initiatives addresses patient safety Implementation of this policy essentially follows aspect independently in India. But they are regarded the ‘’Bottom-up approach’’ (Lipsky, 1980) 3 that is the as standalone exercises and not under one umbrella. implementers or the beneficiaries of the policy play In 2015 during the 68th WHO Regional Committee an important role in the implementation procedure. for South-East Asia, all Member States of the Region, They are not mere managers of policy who follow including India, endorsed the “Regional Strategy for higher authorities rather participate actively. Patients Patient Safety in the WHO (2016-2025)” aiming to recommend developmental needs and deficiencies to support the development of national quality of care work for the future. and patient safety strategies and committed to translate objectives actionable at country level. The main aim of In case of any adverse situation, the health care the National Patient Safety Implementation Framework providers inform the patient and their family members (NPSIF) is to synergize a multitude of initiatives and to and discuss the consequences. Patients’ roles have attain patient safety goals, largely focused on improved emerged from passive recipients of care to more active caliber of care and making headway towards UHC1. and informed co-producers of health. 2 Agenda setting/Problem identification Analyzing the adverse situation and publishing it promotes transparency and helps in future reference for There are a huge number of people who are doctors. 6 Appropriately educated and oriented personnel deprived of secure and suitable medical support and lack are given the responsibility of maintaining client safety a proper national health policy which ensures the proper and their duties have been noticeably conditioned. assessment. Discussing the structural context, India lacks Latest technologies are accepted and organizations proper technology leading to unsafe patient care. Though follow special guidelines on the practices and defenses, there are a number of incident surveillance institutes which ensures high-quality and safe care. Many of the for infection control in India, they lack regulatory implementation procedures are still under progression mechanisms and integrated national level guidelines. since the policy accepts a nine-year action plan. There is a lack of system reporting HAI and there is no authority in place to collect, analyze HAI at the a Policy Evaluation & Monitoring national level. 1 India faces a lot of challenges regarding The organization has observational units and patient safety ranging from unsafe injections, biological personnel in charge of proper functioning of the waste management, high rates of medicines, healthcare- equipments. Specific executives have been assigned associated infections, forming the situational context for obligations to ensure the safe practice and availability the policy. In 2004, a study in an urban slum in Delhi of resources for the same. The followed action plans showed that only 22% of injections used were sterile 322 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
and safe8. According to WHO, there is 1 doctor for 1000 implement the program over 2018-2025. 1 population in India. 2 The strain in the doctor-patient Policy Implementation ratio leads to unsafe health practices. While managing the medical errors, ‘’personal approach’’ or ‘’incident NPSIF focuses to implement in national and sub- blaming’’ also leads practitioners trying to conceal their national levels as well as to public and private sectors. fault which describes the cultural context. Fragmented The MoHFW aims to perform implement NPSIF laws on policies like consumer protection have been efficiently through institutionalization within the existing unsuccessful to classify the rights and privileges of the policy, regulatory and program management framework. patients. Safety studies show additional hospitalization The policy follows the ‘’Top-down approach’’3. At the cause of unsafe health practices, infections acquired in national level, MoHFW constituted National Patient hospitals, DALY cost around US$ 19 billion annually; Safety Steering Committee, will have representation which hampers the national economy. This economic from all relevant governmental and non-governmental loss boosts the interest of stakeholders in patient safety. stakeholders. At the state level, there is a designated Multiple stakeholders and actors were involved in nodal officer appointed. Separate committees are various stages of policy. constituted chaired by the principal secretary in all the states. Similar implementation procedures are carried out Actors in district and village levels. The policy mentions about The major actors in the policy are Directorate involving patients, families, media personnel, etc but General of Health Services, Ministry Of Health & gives the least information about it. Specific budget lines Family Welfare (MoHFW), who with the assistance for patient safety like capacity building, surveillance from the WHO Country Office India, National Health systems, inflectional prevention, and control, etc are System Resource Centre (NHSRC), made the final included in all vertical national programs. The central draft and incorporated the policies at various levels. and state budget establishes national programs. 1 Various other stakeholders were involved in the policy Policy Evaluation/Monitoring like National Accreditation Board for Hospitals and Healthcare Providers, National Quality Assurance Evaluation reveals strategies like baseline assessment Standards, The Central Pollution Control Board, etc. of estimating the burden of unsafe care, funding for and other relevant ministries like defense, railways, and patient safety research were achieved in 100%. Whereas, environment, etc were key government departments and biomedical engineers and a surveillance system are still 1 bodies responsible for formulation and execution. under assembly. The policy also highlights various other priority areas like adverse drug reaction reporting, Policy Formulation establishing hospital transfusion committee, etc. Various NPSIF, developed following a series of legal priority levels are divided and proper intervention and procedures starting from constituting an expert group monitoring teams are engaged. 1 including all major stakeholders and actors, preparing Comparative analysis and approving draft by the ministry to seeking comments of the partners and designing final draft. The content of Albeit both policies describe the same issue, it is the policy covers quality assessment, the intensity of clear that both the countries addressed the problem very adverse events prevention and control of HAI, etc. It differently. While Finland aims to target the intricate also focuses on forming a patient safety campaign and needs of the patients, India still is on the run for the research. fulfillment of basics like safe injection practice, lack of proper technology and regulatory mechanism, etc. MoHFW formulated the entire policy along with The aim of the Finnish policy was to include maximum other ministerial stakeholders. It constituted a multi- participation from patients/clients, whereas India stakeholder Patient Safety Expert Group in August deals with issues like attaining patient safety goals 2016. The group was given the task to operationalize the and progressing towards UHC. In the former policy, patient safety agenda at the country level. The plan is to Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 323 the actors were the beneficiaries whereas ministerial 2. WHO. Patient safety. 2018, August 28. [Cited personnel were the lead actors in the later. Discussing January 26 2019]. Available from: https://www. the problem identification, Finland has problems with a who.int/patientsafety/en/ rapid patient turnover leading to overburdening of work, 3. Buse K, Mays N, & Walt G. Making health policy. professional assault, etc. Similarly, India also faces McGraw-Hill Education (UK). 2007. Available problems like lack of proper technology, no regulatory from: https://www.semanticscholar.org/paper/ mechanism, etc. Analyzing the implementation of the Making-Health-Policy-Buse-Mays/047b12ff3abb5 policies, Finland follows the Bottoms-Up approach, 11b41798c2f0b7d7dfb4c2c1be4 while India follows the Top Down approach. PCSS 4. El-Jardali F, Bou-Karroum L, Ataya N, El-Ghali H appointed specific personnel for monitoring, manage A, & Hammoud R. A retrospective health policy resources, equipment safety. NPSIF established patient analysis of the development and implementation of safety cells at central and district levels, also patient the voluntary health insurance system in Lebanon: safety surveillance system. Learning from failure. Social Science & Medicine. 2014;123: 45-54. Available from: https://pubmed. Conclusion ncbi.nlm.nih.gov/25462604/ 5. Doupi P. National reporting systems for patient To summarize, the paper briefly describes the safety incidents: a review of the situation in comparative policy analysis of a developing with Europe. Raportti/Terveyden ja hyvinvoinnin laitos a developed country, with regard to patient safety (THL)= Report/National Institute for Health and measures. Maximizing involvement of people in policy Welfare. 2009;13/2009. Available from: https:// making, results in better implementation, incorporating www.julkari.fi/handle/10024/80105 the grass-root level needs. Although, working towards 6. Ministry of Social affairs and Health. Patient a common health goal both countries shared a different and Client Safety Strategy 2017–2021. 2017. perspective of problematization, as the needs for a [Cited January 14 2019], Available from: developing country are unlike, those of developed. The https://julkaisut.valtioneuvosto.fi/bitstream/ demands of health and health care identified in Finland handle/10024/80354/11_2017_Patient and client still goes unrecognized in India furthermore the latter safety starategy 2017-2021.pdf?sequence=1 still has a long way to attain UHC. 7. Nurse fined 560 euros for assaulting elderly patient at a Turku hospital. Uutiset. 2017, May Relevance and Recommendation 23. [Cited January 14 2019], Available from: This research helps us understand the disparity of https://yle.fi/uutiset/osasto/news/nurse_fined_560_ health systems in a developed and a developing country euros_for_assaulting_elderly_patient_at_a_turku_ giving room for the research to be taken ahead as to how hospital/9628676 this disparity can be minimized. 8. WHO. India Injection Safety Implementation Project (2016-2018). [Cited 26 January 2019]. Ethical Clearance- No ethical clearance was Available from: http://www.searo.who.int/india/ required to write this since it is a review article. publications/publicatoins_india_injection_safety_ implementation_book.pdf Source of Funding- Self 9. Less than one doctor for 1000 population in Conflict of Interest - Nil India: Government to Lok Sabha. The Economic Times. 2017, July 21. [Cited January 26 2019], References Available from: https://economictimes.indiatimes. com/industry/healthcare/biotech/healthcare/less- 1. MoHFW. National Patient Safety Implementation than-one-doctor-for-1000-population-in-india- Framework (2018-2025). 2018, September. [Cited government-to-lok-sabha/articleshow/59697608. January 14 2019]. Available from: https://main. cms mohfw.gov.in/sites/default/files/national%20 patient%20safety%20implimentation_for%20web. pdf 324 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13869 Immunohistochemical assessment of MMR Proteins, BRAF Mutation and Beta-Catenin in Colorectal Carcinoma in Egypt
Marwa. A. Ahmed1, Mohammed. A. Nouh2, Hoda. Ismael2, Salim. E. Salem3, Ahmed. Rabie4, Asmaa. I. Salama2 1Assistant lecturer, Department of Pathology, National Cancer Institute, Cairo University. 2Professor, Department of Pathology, National Cancer Institute, Cairo University, 3Professor, Department of Medical Oncology, National Cancer Institute, Cairo University, 4Lecturer, Department of pathology, Al-Azhar University
Abstract We conduct this study to investigate the prevalence of dMMR, BRAFV600E mutation and nuclear Beta- Catenin among Egyptian CRC cases and correlate results with clinico-pathological parameters and survival. Immunohistochemical assessment of MMR, BRAF and Beta-Catenin was carried out on 83 CRC cases. dMMR, BRAFV600E mutation and nuclear Beta-Catenin expression were identified in (48.2%), (20.5%) and(4.8%)of cases. For MMR and BRAF, none of the clinicopathologic parameters were significantly correlated with their status. Despite that the 5-year PFS was slightly better in dMMR tumors than pMMR tumors; yet, the statistical difference could not be verified. BRAF mutation had no prognostic impact on OS and PFS. The smaller number of Beta-Catenin positive tumors precluded the drawing of definitive conclusion concerning its prognostic role.
Key Words: CRC, dMMR, BRAF mutation, Beta-Catenin, immunohistochemistry, prognosis.
Introduction syndrome (LS) while promotor hypermethylation of MLH1 is responsible for the majority of dMMR in Colorectal cancer (CRC) is the third most frequent sporadic CRC(5). dMMR can be identified either by the and the fourth leading cause of cancer-associated presence of (MSI) analyzed by (PCR)or lack of protein (1) mortalities worldwide . Although TNM stage remains expression of one of MMR genes, detected by (IHC). the key determinant of patient prognosis, considerable dMMR was associated with distinct clinico-pathologic variability in clinical outcome is likely due to molecular features and better prognosis(6). heterogeneity(2). In cases of MSI, the presence of the BRAF mutation In the past decades, the researchers have investigated excluded the possibility of LS, and the clinical utility a series of biomarkers and pathways including of the combination of these two markers was well microsatellite instability (MSI), mutation in (BRAF) and established. BRAF showed negative prognostic effect in Beta-Catenin which are used as significant prognostic MSS CRC. But its combination with MSI have not been (3,4) factors in intrinsic CRC subtypes . thoroughly investigated(7).
dMMR (defective DNA mismatch repair) is a type Beta-Catenin is the central molecule of the Wnt- of genomic instability and it accounts for 15% of all signaling system. Loss of (APC) function leads to Beta- CRC cases. A germline mutation in one of the MMR Catenin accumulation and its translocation to the nucleus. genes is the cause of dMMR in patients with Lynch This facilitates the transcription of various target genes, contributing to tumor progression. Previous studies had focused on the prognostic role of nuclear Beta-Catenin Corresponding author, in CRC and data from different series were inconsistent Marwa. A. Ahmed, (8). [email protected] Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 325
Patients and Methods Statistics version 22 (IBM® Corp., Armonk, NY, USA). Numerical data were expressed as mean and standard This is a retrospective study included 83 CRC deviation or median and range as appropriate. Qualitative cases diagnosed at the National Cancer Institute, Cairo data were expressed as frequency and percentage. university(NCI-CU) between 2008 and 2013. Thirty- Pearson’s Chi-square test or Fisher’s exact test was used eight were male and forty-five were female. Age ranged to examine the relation between qualitative variables. from 16-74 years with a mean of 50.1 ±1.5 years and Survival analysis was done using Kaplan-Meier method median 52 years. Thirty-three cases (39.8%) presented and comparison between two survival curves was done by proximal colon cancer, followed by twenty-two cases using log-rank test. All tests were two-tailed. A p-value (26.5%) presented by distal colon cancer. Rectal cancers < 0.05 was considered significant. occurred in twenty-eight cases (33.7%). The commonest encountered stage was stage IV; 33 cases (39.8%), Results followed by stage II; 24 cases (28.9%), stage III; 21 cases (25.3%) and lastly stage I; 5 cases (6%). Conventional Prevalence of dMMR, BRAFV600E mutation and adenocarcinoma was the dominant histologic type nuclear Beta-Catenin among cases being detected in sixty-seven cases (80.7%). Mucinous dMMR was detected in 40 (48.2%) cases and they adenocarcinoma was diagnosed in sixteen cases (19.3%). were categorized as follow: Ten cases showed loss of Regarding adenocarcinoma cases, sixty cases (72.3%) expression of all four MMR proteins. Nine cases showed were low grade and seven cases (8.4%) were high grade. lost expression of three of MMR proteins. Combined loss Associated polyps were seen in eleven cases. Lymph of two proteins was detected in thirteen cases. Isolated node metastasis was detected in thirty-seven cases while loss of one protein was detected in eight cases with no distant metastasis was detected in thirty-three cases. evidence of isolated MSH6 loss. BRAF mutation was Positive family history was recorded in six cases (7.2%). identified in 17 (20.5%) cases, 7 of them were dMMR Fifty-eight cases received adjuvant chemotherapy while and 10 were pMMR. Only 4 cases (4.8%) exhibit Beta- fourteen cases received adjuvant radiotherapy. Catenin nuclear expression, all are seen among pMMR Immunohistochemistry tumors.
Immunostaining was done using Bench Mark XT Correlation of dMMR, BRAF mutation and (Ventana) autostainer. Slides were incubated with the nuclear Beta-Catenin with clinico-pathological following ready to use mouse monoclonal antibodies: characteristics MLH-1 (clone G168-728; Cell Marque), MSH-2 For MMR and BRAF, none of the examined factors (clone G219-1129; Cell Marque), MSH-6 (clone 44; were found to be significantly associated with their status Cell Marque), anti-BRAF V600E (VE1) (Ventana (Table 1).The small number of Beta-Catenin positive Medical Systems, Inc., Cat. Number 790–4855), cases hindered assessment of its association with these Beta-Catenin (14) Cell Marque with dilution range factors. from 1:25-1:100 and rabbit anti-human PMS2 (clone EPR3947; Cell Marque).According to the CAP protocol Survival Analysis for immunohistochemistry interpretation, dMMR The median follow-up time was 15.2 months. At was consideredwhen nuclear staining was absent for the end of follow up period, 55 patients were alive and at least one proteinprovided that internal controls 28 patients were deceased. Univariate analysis was were positive(6) (Figures1,2). For BRAF, positive performed and the relation between clinicopathologic cytoplasmic staining indicated its mutation (10) (Figures parameters and survival was illustrated in (Table 2). 1,2). For Beta-Catenin, cases with nuclear staining only The 5-year PFS was slightly better in dMMR cases were considered positive (11). (51.1 months) than pMMR cases (28.9 months) but Statistical Methods the statistical difference could not be verified. BRAF mutation had no prognostic impact on both OS and PFS. Statistical analysis was done using IBM SPSS® For Beta-Catenin, the small number of positive cases 326 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 precluded the drawing of definitive conclusion concerning its prognostic role.
Table(1): Association between MMR/BRAF status and clinicopathologic characteristics
MMR status BRAF status
pMMR dMMR Wild type Mutant type Characteristics p-value p-value (n=43) (n=40) (n=66) (n=17)
Age (yrs)
· ≤ 50 years 18 (47.4%) 20 (52.6%) 31 (81.6%) 7 (18.4%) 0.457 0.669 · > 50 years 25 (55.6%) 20 (44.4%) 35 (77.8%) 10 (22.2%)
Sex
· Male 19 (50%) 19 (50%) 0.762 28 (73.7%) 10 (26.3%) 0.226
· Female 24 (53.3%) 21 (46.7%) 38 (84.4%) 7 (15.6%)
Site
Stage
Proximal colon 15 (45.5%) 18 (54.5%) 24 (72.7%) 9 (27.3%) Distal colon 11 (50%) 11 (50%) 0.484 18 (81.8%) 4 (18.2%) 0.435 Rectum 17 (60.7%) 11 (39.3%) 24 (85.7%) 4 (14.3%)
· I 1 (20%) 4 (80%) 0.296 4 (80%) 1 (20%) 0.950
· II 13 (54.2%) 11 (45.8%) 20 (83.3%) 4 (16.7%)
· III 9 (42.9%) 12 (57.1%) 16 (76.2%) 5 (23.8%)
· IV 20 (60.6%) 13 (39.4%) 26 (78.8%) 7 (21.2%) *Histologic grade
· Low 30 (50%) 30 (50%) 49 (81.7%) 11 (18.3%) 1.000 0.792 · High 4 (57.1%) 3 (42.9) 6 (85.7%) 1 (14.3%)
Histologic subtype · Adenocarcinoma 34 (50.7%) 33 (49.3%) 55 (82.1%) 12 (17.9%) · Mucinous 9 (56.3%) 7 (43.7%) 0.692 11 (68.7%) 5 (31.3%) 0.235 adenocarcinoma
*L. node metastasis · Yes 15 (40.5%) 22 (59.5%) 26 (70.3%) 11 (29.7%) 0.345 0.384 · No 20 (54.1%) 17 (45.9%) 31 (83.8%) 6 (16.2%)
Distant metastasis 13 (39.4%) 26 (78.8%) 7 (21.2%) 0.893 · Yes 20 (60.6%) 0.192 27 (54%) 40 (80%) 10 (20%) · No 23 (46%)
*Grading was applied to conventional adenocarcinoma cases only. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 327
*Nine cases were not included as they were stage IV not underwent surgery.
Table(2):OS and PFS and their relation to clinicopathologic characteristics and prognostic factors
Cumulative Cumulative P P Characteristic No. of cases OS at 5 year value PFS at 5 year value (%) (%)
Total 83 53.5 39 Age 0.123 0.017 · ≤50 38 61.6 55.1 · >50 45 45.5 23.8 Gender 0.005 0.011 · Male 38 38.4 28.6 · Female 45 66.5 49.1 Site 0.817 0.868 · Proximal colon 33 47.1 51.6 · Distal colon 22 56.8 33.4 · Rectum 28 56 38.7 Stage 0.001 0.000 · I 5 NR NR · II 24 80 57.6 · III 21 76.6 65.1 · IV 33 23.2 7.9
Histologic type 0.263 0.119
· Adenocarcinoma 67 49.5 32.4 · Mucinous adenocarcinoma 16 73.9 71.4 Histologic grade 0.352 0.951 · Low 60 46.7 30.8 · High 7 83.3 41.7 L.node metastasis 0.108 0.418 · Yes 37 46.5 47.9 · No 37 71 39.9 Distant metastasis 0.001 0.000 · Yes 33 23.2 7.9 · No 50 78.5 63.3
MisMatch Repair 0.202 0.096
· pMMR 43 48.9 28.9 · dMMR 40 57.8 51.1 BRAF 0.670 0.949 · Wild 66 53 36.6 · Mutant 17 54.1 47.5 MMR /BRAF 0.518 0.365 328 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
· pMMR/BRAF wild 33 46.5 25.9 · pMMR/BRAF mutant 10 57.9 41.1 · dMMR/BRAF wild 33 58.2 49.6 · dMMR/BRAF mutant 7 51.4 51.4
NR: not reached five-year survival. pMMR: MisMatch Repair gene-proficient. dMMR: MisMatch Repair gene- deficient. OS: overall survival. PFS: progression free survival.
Figure (1): Adenocarcinoma with pMMR/wild BRAF. (A) Hx&E (x100). (B) MLH1, (C) PMS2, (D) MSH2, (E) MSH6, (x100). (F) Wild BRAF(x 100).
Figure (2): Adenocarcinoma with dMMR/mutant BRAF. (A) Hx&E (x100). (B) MLH1 and (C) PMS2; both showed non-specific cytoplasmic staining (x400). (D) MSH2 and (E) MSH6; both showed intact nuclear staining(x100). (F) Mutant BRAF(x400). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 329
Discussion previous reports (17,18,19). Others conclude that dMMR was associated with improved survival(6,9,15,20). The In this study, we performed analysis of MMR most important reasons for these discrepant data include status, BRAF mutation and Beta-Catenin in CRC using variability in sample size, heterogeneity of patient’s immunohistochemistry. characteristics, different antibody clones and techniques The frequency of dMMR is found to be variable used for assessment of MMR status. But in our series, in different studies ranging from 6.9% among Chinese this might be due to increased prevalence of stage IV populationto34% among Pakistani population (5,12). Our among studied cases. Such findings support the fact that study and another recent Egyptian one found a higher better prognosis of dMMR is more apparent in earlier incidence of dMMR among Egyptian CRC cases (48.2% stage tumors. and 67%, respectively)(13). Such discrepancy could be As regard BRAF, our data and the previously attributed to racial differences. reported onesfoundno difference in the survival between Three (3.6%) of our cases showed isolated loss of BRAF wild and mutant groups(6,15). PMS2 while isolated loss of MSH6 could not be detected. Combinational analysis of MMR and BRAF status Similar findings were obtained by previous studies(5,13) . was done. With respect to BRAF mutational status, In our series, none of the clinico-pathologic no difference in the survival was seen among both parameters seem to be significant with MMR status. pMMR and dMMR groups. Previous studies mentioned This is in line with other studies (12,14). Only Hashmi that in patients with MSI, mutation in BRAF didn’t and colleagues showed significant correlation between significantly affect survival time but patients with MSS/ MMR status and tumor site. In his study cases were mutant BRAF had poorer prognosis than patients with classified in to right and left side without clarification MSS/wild BRAF(9,21). Our results should be interpreted of extension. carefully as the difference with these two studies may be due to smaller number of our cases (83 cases) compared The relation between dMMR and the to larger number of their cases (762 and 2036 cases clinicopathologic characteristics was found to be respectively). heterogonous in previous studies done with different results obtained(5,6,8,9,15,16). Discrepancy between these In conclusion, the prevalence of dMMR in our study studies may refer to considerable variation in term of is relatively high in comparison to international literature. patient’s characteristics and tumor parameters. Both dMMR and BRAF mutation appeared to be of no prognostic value.Further evaluations are warranted to BRAF mutations was detected in 20.5% of cases identify the prognostic role of MMR, BRAF and Beta- with more incidences seen among pMMR tumors. We Catenin as this question requires pooled study to obtain could not find any association between BRAF mutations large sample size. and clinicopathologic characteristics similar to previous study (6). Conflicts of Interest: None
In our study, only four cases (4.8%) exhibit nuclear Ethical Clearance: Taken from Ethical Institutional expression of Beta-Catenin, all were distributed among Review Board of NCI, CU. pMMR tumors. The small number of positive cases Source of Funding: This study was supported by hinder to assess its association with clinicopathologic NCI, CU. characteristics and survival.
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Md. Sayedul Islam1, Md. Rashidul Islam2, Md. Tuhinur Rahman3, Mst. Umme Habiba4, Md. Nahian Rahman5, Oumma Halima6 1Lecturer, Department of Microbiology & Public Health, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur-1706, Bangladesh, 2Lecturer, Department of Animal Science and Nutrition, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur-1706, Bangladesh, 3Lecturer, Department of Surgery and Radiology, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur-1706, Bangladesh, 4Research Assistant, Department of Environmental Science and Technology, Jashore University of Science and Technology, Jashore-7408, Bangladesh, 5Senior Officer, Bangladesh Krishi Bank,6 Assistant Professor, Department of Food Technology & Nutrition Science, Noakhali Science & Technology University, Noakhali-3814, Bangladesh
Abstract Salmonella is one of the etiological agents of intestinal illness as well as typhoid and paratyphoid fever throughout the world. While food is known to be a common vehicle for the transmission of typhoidal Salmonella serovars, non-typhoidal Salmonella are mainly known as foodborne pathogens. But recent studies found water as vehicle for transmission of Salmonella serovars. And several studies have showed the role of contaminated water in Salmonella foodborne illness. So, this paper provides a brief review of the last twenty years of peer reviewed publications on the prevalence of Salmonella in environmental water, and relationship between contaminated water and Salmonella foodborne infections. Salmonella represent zoonotic bacteria that are distributed throughout the world. Data relating to Salmonella prevalence in water indicated a mixed human and animal origin of Salmonella contribution to water contamination. This study has also emphasized on the role of these contaminated water in occurring Salmonella foodborne diseases and its implication on global public health problem.
Key words: Pathogenic bacteria, Salmonella, Environmental water, Foodborne illness, Water pollution
Introduction Contamination of water by pathogenic microorganisms is now a growing problem. The possible Environmental water, though a vital component sources of these bacteria in the aquatic environment are of ecosystem is being polluted day by day. Therefore, the discarding of human waste and municipal wastewater Waterborne illness and multiple epidemics associated into the environmental water through improper drainage with the consumption of contaminated or improper and sewage disposal facilities. Previous studies showed treatment of water are gradually raising global public that human pathogenic bacteria, particularly members health concern. Both surface water and groundwater of the coliform can inhabit on fishes and aquatic sources are being contaminated with different kinds of environment (2). Feces of warm-blooded animals can hazards like chemical, physical and biological hazards harbor fecal coliforms and they are the most used since water is directly exposed to people’s domestic indicators of fecal pollution in water and food. Increased purposes, pollution from untreated industrial effluents, levels of fecal coliforms provide a warning of failure of municipal wastewater, runoff from chemical industry the water distribution system and possible contamination and agricultural fields and oil and lube spillage from with other pathogens such as E. coli, Shigella spp., different operation, fecal contamination, and aquatic Salmonella spp., Vibrio etc. (3). Water become unsafe pathogenic microorganisms (1). for human consumption or usage when it contains pathogenic or diseases causing microorganisms. The Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 333
consumption of unhygienic drinking water and uses of Criteria for Considering Studies for Review unsafe water for daily purposes lead to the prevalence Potential items of interest were selected for of diseases like diarrhea, typhoid, cholera and bacillary inclusion in this literature review if they represented dysentery among the population (4). one of the following criteria: (a) contaminated water; Salmonella is a ubiquitous enteric pathogen that (b) environmental water; (c) foodborne illness; (d) are distributed throughout the world. They comprise salmonella, and (e) wastewater. a large number of serovars characterized by different Selection of Studies host specificity and the apparent ability to cause disease (5) in those hosts . This microorganism is one of the Among the articles searched, only papers linked to leading causes of intestinal illness through the world the study selection criteria were added to this paper. On as well as the etiological agent of more severe systemic the other hand, papers that were unable to follow the (6,7) diseases such as typhoid and paratyphoid fever . study selection criteria were excluded from the study. Zoonotic Salmonellae are commonly described as After reviewing more than 100 full original research and foodborne pathogens, however, drinking water as well systematic review articles, information from 70 relevant as natural waters are known to be an important source references were included in the research paper. No (8). for the transmission of these enteric microorganisms constraints were imposed on release year. The studies Salmonella is present in marine and fresh environmental included must be primary studies or papers that include (9,10) surface waters but acute contamination of these secondary interpretation of the results from these studies environments may come from one or multiple routes, and published in a peer-reviewed journal or book. It such as wastewater treatment plant discharges, urban included only English language papers. and/or agricultural runoff pollution, overburdened septic systems, or contact with local and migratory Molecular identification ofSalmonella spp. fauna (11,12,13). Due to the persistence of Salmonella in Molecular biology assays are being used to detect environmental waters, there might be a greater public and differentiate salmonella species in recent years. health concern than previously thought. In some cases, 16S rRNA primer was used to detect Salmonella spp. growth outside host organisms leading to the probability in water source used for shrimp farm. That study of survival between hosts (14). In line with Salmonella indicated 28.7% of water and 25.5% of sediment isolates water pollution, surface waters used for irrigation as Salmonella spp., while PCR test gave positive for have been identified as a source of contamination 7.44% and 5.15% of the isolates, respectively. In search of horticultural crops related to outbreaks. Raw or of prevalence of Salmonella spp. in wastewater sample, minimally processed vegetables may be contaminated which is frequently reused for irrigation, molecular assay with Salmonella, with subsequent direct infection of has been used to detect Salmonella spp (16). In another consumers or cross-contamination of other foodstuffs, study, 23S rRNA oligonucleotide probe was used to be which could represent a severe health risk (15). And this confirmed aboutSalmonella spp. Also, they used specially study aims to link between contaminated water and designed primers ST1-1 and ST1-5 which amplify the Salmonella foodborne infections. Salmonella sp. specific chromosomal fragment of 429 Methods bp. 76 Salmonella spp. were found positive against ST11 and ST15 primers (17). A new research was aimed to Search Methods for Identification of Studies screen Salmonella sp. using the 16S rRNA, to determine A literature search of the electronic databases of whether the invA gene is specific for Salmonella PubMed, Cochrane Library, Murphy Library and Google detection as well as virulence genotyping of some genes Scholar was carried out until 2020. Using Record Title, present in Salmonella sp. (invA, sitC and spvA, spvB Title Abstract Keywords, Keywords, and Medical and spvC) from food samples in Lagos, Nigeria. All Subject Headings (MeSH) terms required papers were 76 isolates tested positive for 16SrRNA gene while 53 selected to isolate data and information for this study. (69.7%) were positive for salm3 and salm4 (389 bp) gene. PCR analysis of the invA gene (284bp) showed 334 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
that 73 (96.1%) were positive, 38 (50%) of the isolates Drinking water containing Salmonella is a threat to were positive for sitC gene while none were positive for human health. These bacteria can cause diarrhea, nausea, spvA and spvB and with the multiplex –PCR of invA/ abdominal cramps, fever, and vomiting (22). Some spvC gene, 25(33%) were positive for invA (244 bp) studies have also been reported a statistically significant gene and nonpositive for spvC gene. In another study, increase in gastrointestinal illness in populations samples are collected a total of 32 from shops around the that drink contaminated water with different types of North West Province, South Africa and analyzed for the coliform bacteria. Another study found prevalence presence of Salmonella species. A total of 96 presumptive of Salmonella 8.3% to 16.7% in different location of isolates were screened for characteristics of Salmonella. Acheron River, Kalamas River and Ionian Sea coastal To avoid bias, all the 96 isolates were screened for the waters. They isolated 28 serovars of Salmonella spp. and Salmonella specific inv-A gene through PCR analysis then identified asSalmonella enteritidis (23), Salmonella and only 10 (10.4%) isolates were positively identified. thompson (3) and Salmonella virchow (2). From the Moreover, none of the isolates possessed the flic-C isolated serovars 34.8% of S. enteritidis and 100% of S. flagella genes while a small proportion 11(11.5%) were virchow being resistant to more than 3 antibiotics. (AMP, positive for the fljB gene fragments (19). Another study AK, AMC, CXM, CIP, FOX). Salmonella enterica also aimed to employ biochemical and molecular assays serovar Enteritidis is the commonest serovar isolated to detect and diagnose Salmonella in wastewater. For from human salmonellosis cases in Greece (24) and this this reason, two water samples were collected from serovar is the most often isolated from hen flocks in Alexandria wastewater treatment plant (S1) and septic Greece (25). Human cases are frequently associated with tank of a hospital at Alexandria governorate (S2). contaminated poultry (24) and S. enteritidis is most likely As a confirmatory, species-specific PCR assay was the untreated sewage effluents of urban or rural (mainly performed for 17 randomly selected bacterial isolates from nearby livestock farms) origin. The prevalence from both water samples. Positive-PCR Salmonella rate in water sample used in mid-Atlantic tomato farms isolates (5 from S1 and 4 from S2) were subjected for found 7.7% to 15.4% and four out of the 14 farms identification using API 20E biochemical identification (29%) and 12 out of 1,091 samples (1.1%) were found kit. Subsequently, PCR-RFLP of 16S and 23S rDNA to harbor Salmonella enterica subsp. Enterica (26). Pond genes, Rep-PCR fingerprinting and plasmid profile were water, rhizosphere soil, control soil, irrigation ditch employed to recognize among isolates (20) . water was found as positive environmental sample. Salmonella was detected on 4 out of 14 (29%) tomato Prevalence of Salmonella in environmental water farms included in the study; 4 out of 9 (44%) large-scale Though gastro-intestinal tract of animals is the farms and 0 out of 5 (0%) small-scale farms. Another most common vehicle for salmonella, it is greatly study detected 6% (6/96) Salmonella spp. in irrigation found in environmental water. A recent study found the water and 4.3% (3/67) in sediment sample. Water and prevalence of Salmonella spp. 2% in well water sample, sediment samples collected from various points along 15% in water of reservoir of Tanghin, 20% in reservoir irrigation systems, and from streams and ponds on farms of Yamtenga, 20-30% in city water channel. Total 50 on the Central California coast between May 27th, 2008 (27) different serotypes of Salmonella sp. isolates were and October 26th, 2010 . Surface water in Central found. Among them 11 most common serotypes were Florida was also be contaminated with Salmonella and it Salmonella bredeney and S. Colindale (both 8.2 %), S. was identified 165Salmonella positive sample from 202 (28) Muenster (6.1 %), S. Korlebu (5.1 %), S. Eastbourne and total sample . The prevalence rate of Salmonella spp. S. Poona (both 4.1 %), and S. Agona, S. Derby, S. Drac, In Lake Zapotlán, Jalisco, Mexico was 30.15% (19/63) S. Senftenberg, S. Waycross (each 3.1 %), accounting and total 63 water samples were collected from June to for 51.3 % of all the isolates (21). This high diversity of October 2016 monthly from 14 defined sampling area (29) Salmonella serotypes in aquatic environment can lead . The prevalence of Salmonella spp. was positively to human Salmonella infections by linking human to correlated with different factor viz. air temperature, surface water. In the southern area of Isfahan, 5.55%, electrical conductivity, pH, and dissolved oxygen and of tap water samples were positive for Salmonella spp. negatively correlated with relative humidity, water Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 335
temperature, turbidity, and precipitation. 87% positive followed by Chloramphenicol and Amikacin (96%), samples were found in a river water mixed comprising Gentamycin (90%), Amoxicillin (82%), Streptomycin untreated sewage of residential setup in India (30). They (80%), Tetracycline (76%), Nalidixic acid (68%), used 8 sampling sites and the load of Salmonella found Ampicillin (58%) and Sulfonamide (10%). The as 104 –106 CFU/100 ml. The watersheds systems in resistance was highest for Sulfonamide (76%) followed four swine production residential/industrial forestry crop by Ampicillin (32%), Nalidixic acid (30%) and 6-20% agriculture contain 54% Salmonella positive sample for Gentamycin, Amoxicillin and Tetracycline (35). The from 4 sampling sites in USA (31). In another studies the reports of salmonellosis caused by Salmonella enterica prevalence rate of Salmonella found 0.89% when total serovar significantly increased over the years 2007- 448 samples of tap water and mineralized bottled water 2011 (36). A high prevalence of multidrug-resistant were tested (32). Among the samples of 144 tap water isolates, mainly showing an Ampicillin-Streptomycin- 3.47% was positive for IpaB gene. In the southern area Sulfonamide-Tetracycline resistance pattern (ASSuT), of Isfahan, 5.55%, of tap water samples were positive was observed. Another study identified a total of 165 for Salmonella spp. Among the samples of 144 tap water Salmonella enterica isolates from 1382 samples taken 3.47% was positive for IpaB gene. The prevalence study from conventional farms, abattoirs and retail markets shows that ponds, lake, rivers and canal (13, 4, 2 and 1) from 2010 to 2011 in Sichuan, China. Among these in different location of Tangail District of Bangladesh isolates, S. enterica serotypes derby (76 isolates, 46%) found 5 Salmonella positive sample out of 20 water and typhimurium (16 isolates, 10%) were the most samples (33). They found most of the water sampling prevalent, and high antimicrobial resistance observed spot were polluted by dumping waste, cattle wash and for Tetracycline (77%), Nalidixic acid (41%) and were not unable to drink or other domestic purposes. Spectinomycin (41%) (37). They found 55% (11 out of 20) of the sampling spot was Role of contaminated water in Salmonella polluted by directly dumping of waste. foodborne illness: Antibiogram profile of Salmonella spp. Water plays an important role as source of Salmonella spp. isolated from water of shrimp contamination for Salmonella spp. specially in pre farm were resistant to sulfonamide (SF), but sensitive and post-harvest processing (38,39). According to the to tetracycline (TC), chloramphenicol (CAP), and Centers for Disease Control and Prevention 53.4% furazolidone (FZ) (16). In a study 12 commonly used of all foodborne disease outbreaks from 2006 to 2017 antibiotics was tested against detected Salmonella spp. associated with Salmonella, and approximately 32.7% isolated from wastewater and ready to use irrigation of these foodborne outbreaks were associated with water sample to see the antibiotic resistance patterns. consumption of produce (40). Water with compromised They found two multiple drug resistance (at least three microbial quality is using for drinking, washing and antibiotics) Salmonella spp. Resistant to tetracycline irrigation in developing country along with many was the most common one, reaching 66.7 to 69.2%. developed countries. For example, in United Kingdom Percentage of resistance to ampicillin showed 11.1% they use surface water for irrigation up to 71% which and 7.8% in both secondary wastewater treatment specially comes from treated sewage effluent (41). plants. No isolate was resistant to amikacin, amoxicillin/ Another available data on Salmonella showed that the clavulanic acid, ceftriaxone or ciprofloxacin. One isolate surface water is heavily contaminated with Salmonella found resistant against 6 antibiotics (17). Salmonella spp. (31,42,43,44,45,46,47). On the other hand, in natural strains were sensitive to the antimicrobials tested, but aquatic condition Salmonella produce biofilm and can two strains were resistant to streptomycin and many persist long period of time (2,48,49,50,51,52). Salmonella more intermediate to streptomycin or sulphonamide was also isolated from mineralized bottled drinking (21). All the isolated Salmonella strains were sensitive to water in Isfahan, Iran and is very alarming for public Cefotaxime and Ciprofloxacin, and 100% were resistant health (32). Untreated wastewater is frequently used to Nalidixic acid, Tetracyclin and Sterptomycin (34). The for irrigation which increasing the public health risk sensitivity of S. enteritidis was 100% for ciprofloxacin through cross contamination (40,53). Contamination of 336 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
vegetables, fruits and other foodstuffs with Salmonella In farm, cross contamination is occurring frequently spp. are quite common scenario. In most of the cases between irrigation water and agricultural produce. it is caused by the cross contamination between foods Therefore, Salmonella are entering into food chain and environmental water like wastewater and irrigation through water channel and occurring greater health risks water. Consumption of fresh fruits and vegetables can for human and as well as for animals. be a quite common way of being infected with enteric Acknowledgements: The authors would like to pathogens (54). Some published reviews stated the role acknowledge the support of Department of Microbiology of transmission of enteric pathogen like salmonella from & Public Health, Department of Animal Science and fresh food to human (39,52,55,56). Highly contaminated Nutrition Bangabandhu Sheikh Mujibur Rahman irrigation water is a great source of Salmonella to Agricultural University, Department of Environmental contaminate edible part of the plants (57). It is proved in Science and Technology, Jashore University of Science case of parsley by the scientific data (58). Recent study and Technology, Department of Food Technology & summarized that irrigated lettuce is highly affected Nutrition Science, Noakhali Science & Technology with Salmonella enterica through the water used for University. irrigation (21,57). In mid-Atlantic tomato farms different Salmonella serotypes has been isolated from fresh Funding: The authors received no specific funding tomato and there have evident of use of contaminated for this work. ground and pond water for irrigation. Though the level of contamination of ground water was very low and Ethical Clearance: Ethical Approval: Not the pond water was highly contaminated (59). A broad Applicable spectrum of fresh vegetables and fruit are associated Conflict of Interests: The authors declare that they with different kinds of Salmonella serotypes such as have no conflict of interest. tomato (60,61), cantaloupe (62), basil (63), lettuce (57), and (64) Mango . Water with poor microbiological quality act References as a source of contamination for leafy green produce. 1. Hassan R, Buuck S, Noveroske D, Medus C, This contaminated water which is used both for Sorenson A, Laurent J, Rotstein D, Schlater L, irrigation and washing can elevate the level of bacteria Freiman J, Douris A, Simmons M. Multistate like Salmonella in leafy green produce(27). Pathogen like Outbreak of Salmonella Infections Linked to Raw Salmonella have the ability to invade plant tissue and it Turkey Products—United States, 2017–2019. (58,65,66,67) is reported by several studies . Now a days in Morbidity and Mortality Weekly Report. 2019 Nov Europe inflow water is using for trout farm. This water 22;68(46):1045. working as a source of contamination for Salmonella 2. Saha ML, Nessa M, Khan MR, Islam MN, Hoque S. through the marketed trout (68). Recent study in Pakistan Bacteriological and physicochemical water quality found ceftriaxone resistant Salmonella enterica from of four ponds of dhaka metropolis. Bangladesh the sample of household drinking water and community Journal of Botany. 2012 Jul 1;41(1):55-60. water (69,70). 3. Tallon P, Magajna B, Lofranco C, Leung KT. Microbial indicators of faecal contamination in Conclusion water: a current perspective. Water, air, and soil This review on the prevalence and risk of Salmonella pollution. 2005 Sep 1;166(1-4):139-66. in water and therefore leading to foodborne diseases has 4. Moe CL, Rheingans RD. Global challenges in demonstrated the ubiquitous nature of Salmonella. It can water, sanitation and health. Journal of water and be present in a variety of aquatic environments and that health. 2006 Jul;4(S1):41-57. contamination can come from a range of sources. Several 5. Andino A, Hanning I. Salmonella enterica: PCR positive pathogenic serotypes of Salmonella spp. survival, colonization, and virulence differences found in irrigation water used in agricultural production among serovars. The Scientific World Journal. as well as in city water channel. Even this bacterium 2015 Oct;2015. has been found in mineralized bottled drinking water. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 337
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Mkpoikanke Sunday Otu1, Kay C. N. Onyechi2, Chiedu Eseadi3, Raphael Oluwasina Babalola Folorunsho4,5 1Lecturer, 2Professor, 3Lecturer, Department of Educational Foundations, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria, 4Family Physician, Family Medicine Department, Tawam Hospital, United Arab Emirates, 5Adjunt Lecturer, United Arab Emirates University (UAEU), United Arab Emirates
Abstract This article aimed at discussing the clinical significance of cognitive behavior language therapy in treating aphasia among stroke patients. The present discussion was based on empirical evidence found in the literature. The result of this review shows that cognitive-behavior language therapy has a clinical impact in treating aphasia among stroke patients. The reviewed study reported a significant reduction in aphasia and speech-language unhelpful thought and beliefs. Also, the need for more randomized trials to further express the clinical impact of cognitive behavior language therapy for aphasia following stroke was emphasized.
Keywords: aphasia, clinical impact, cognitive behavior language therapy, stroke patients
Introduction for the disease. Majority of the treatment neglect the cognitive restructuring process. But recently, a Stroke is one of the major causes of aphasia. The cognitive-behavior language program, involving speech minor causes of aphasia are brain tumors, infections, and restructuring became an evidence-based treatment for head trauma1. Aphasia following stroke is a linguistic aphasia3. It has been justified that aphasia treatment impairment related to someone’s brain scratch2 and should be geared towards improving cognitive abilities causes effects on speech production, comprehension, in order to support short-term memory and attention3. writing, and reading. Thus, aphasia patients are It could be that aphasic patients are prone to unhelpful diagnosed with improper, inadequate and poor thoughts and beliefs. That being the case, a cognitive- communication styles. In a severe state, the patients may behavioral language program, involving speech have an impossible communication challenge3,4. This restructuring became an evidence-based treatment for communication challenge may end the patients and their aphasia will have numerous clinical impact. families in negative life experiences like depression, limited participation in activities, social isolation, loss of Cognitive behavior language therapy (CBLT) autonomy, and restricted development of relationships4. encompasses the application of the principles of cognitive behavior therapy (CBT) to treat aphasia following Studies done in the past have indicated that the rate stroke3. From previous evidence, people usually have of aphasia following stroke is high5. This high rate of the tendency to think erroneously and their thought aphasia following stroke has been a major cause of death influences their emotions and behavior3,7. Thus, in CBT in many countries, including Nigeria3,6, despite the fact related interventions, patients’ thoughts, emotions, that medical experts have developed series of treatments and behaviors are examined and corrected7. Studies have demonstrated that CBT-related interventions are Correspondence: effective in the treatment of decreases like anxiety, Chiedu Eseadi, social avoidance, depression, stress, burnout and 3, 5 Department of Educational Foundations, University of language deficit . This is why the techniques that are Nigeria Nsukka, P.M.B. 410001, Enugu State, Nigeria. used in CBLT are drawn from a widely CBT model for E-mail: [email protected] treating clinical cases. Cognitive behavior language 342 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
therapy (CBLT) is designed to help aphasic patients increasing participants’ capacity to attend to alternative to change their unhealthy thoughts and beliefs that cognitive and behavioral targets regarding language hamper their language and communication processes, use3. with the aim of improving the patients’ ability toward Seeing the efficacy of cognitive behavior language communicating adequately. To achieve this aim, aphasic therapy for aphasia following a stroke in the reviewed patients are helped to use remaining language, abilities, study, it is noted that more randomized studies are restore language abilities as much as possible. They are needed in the application of CBLT for aphasia following also helped to learn different communication patterns stroke. This will help to further ascertain the efficacy such as gestures, pictures, or use of electronic devices. of cognitive behavior language therapy to reduce This paper aimed at discussing the clinical impact of aphasia among stroke patients. This is in line with the cognitive behavior language therapy in treating aphasia recommendations made by the authors of the reviewed among stroke patients. study that large scale, randomized, controlled trials of Methods CBLT for aphasic patients be conducted in Nigeria and in other nations3. We used Google Scholar and PubMed to search for studies published on CBLT among aphasic adult In such a study, the patients should be helped to patients with stroke. We examined both pay-per-view, focus on evidence word, rather than on their personal peer-reviewed, and open access articles, but synthesized reasons for believing their unhealthy thoughts. Thus, in information from only one article which focused accordance with the reviewed study, the patients in the on cognitive behavior language therapy for aphasia future CBLT study should be made to answer questions following stroke. Following the outlines provided in the regarding the evidence they have against their thoughts; previous studies for treating language deficit disorders8. how their thoughts made them feel; and the good things We also examined how the authors developed, validated they would gain if they gave up the thoughts. The and implemented CLBT3. therapists in the future studies should use techniques like verbal and nonverbal support, appropriate tone of voice, Results and Discussion humor, direct training, behavior technique, role-play, One study has, to date, used cognitive behavior psycho-education, exposure, cognitive restructuring, language therapy to help stroke patients with aphasia.3 emotive technique, homework, and other relevant CBLT The study reported a significant reduction in aphasia techniques. However, it is worth noting that there should following a stroke and speech-language unhelpful be activities like speaking, listening, writing, reading thoughts and beliefs among aphasic stroke patients3. skills. Also, the patients should be helped to identify and Thus, the CBLT achieved its goal which was to reduce dispute their unhealthy thoughts and beliefs, regarding aphasia following stroke. Through the intervention, the specific language activities such as listening, speaking, aphasic stroke patients were helped to use their remaining reading, and writing skills. language abilities; restore language abilities as much Also, we recommend that future researchers in the as possible; and learn other ways of communicating, area of CBLT should adopt the strategy of the use of including using gestures, pictures, or electronic devices3. caregivers, which the reviewed study also used3. To The authors designed CBLT for the reviewed study further support this, previous research observed that to cover 20 sessions across 10 weeks with 4-weeks. when the aphasia is severe, intervention programs Also, there were follow-up sessions 2 months after the would require the service of trained caregivers4, 9. completion of initial treatment. The organization of the The caregivers should be trained to become direct CBLT in the study reviewed had both individual sessions communication partners with the responsibility of and small group sessions. The individual sessions focused facilitating and encouraging communicative interactions on the specific needs of the patient while the small group with their aphasic patients10. Also, aphasia education, sessions availed the aphasic patients the opportunity to communication, and counselling should be the focus of use new communication skills. The authors clearly noted the training for the caregivers. Finally, the caregivers that the aim of the CBLT intervention was achieved by Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 343 should be taught how to give the CBLT therapists behavior language therapy for aphasia following feedback about their patients. stroke: Implications for language education research. Medicine. 2019;98(18):. Conclusion 4. McLean SC. A Communication Partner Training Our review noted that cognitive behavior language Program for Individuals With Aphasia Secondary to therapy is efficacious in reducing aphasia among aphasic a Traumatic Brain Injury: A Case Study: Southern stroke patients exposed to the treatment intervention Connecticut State University; 2017. when compared with the no-treatment. It is unfortunate 5. Ellis C, Hardy RY, Lindrooth RC, Peach RK. that only one study was found in this area. Thus, more Rate of aphasia among stroke patients discharged randomized trials are needed to further express the from hospitals in the United States. Aphasiology. 2018;32(9):1075-1086. clinical impact of cognitive behavior language therapy for aphasia following stroke. Also, future studies should 6. Laska A, Hellblom A, Murray V, Kahan T, Von be built to uplift the limitations found in the reviewed Arbin M. Aphasia in acute stroke and relation study such as small sample size, lack of qualitative and to outcome. Journal of Internal Medicine. 2001;249(5):413-422. demographic data. 7. Beck JS, Beck A. Cognitive behavior therapy. New Conflict of Interest – Nil York: Basics and beyond Guilford Publication. 2011. Ethical Clearance- Not required 8. Menzies RG, Onslow M, Packman A, O’Brian S. Source of Funding- Self Cognitive behavior therapy for adults who stutter: A tutorial for speech-language pathologists. Journal References of Fluency Disorders. 2009;34(3):187-200. 1. Velez Diaz LA. An Exploration of Research and 9. Meier EL, Johnson JP, Villard S, Kiran S. Does Resources Related to Aphasia: Creating a Resource naming therapy make ordering in a restaurant Guide. 2018. easier? Dynamics of co-occurring change in cognitive-linguistic and functional communication 2. Ellis C, Urban S. Age and aphasia: a review of skills in aphasia. American Journal of Speech- presence, type, recovery and clinical outcomes. Language Pathology. 2017;26(2):266-280. Topics in Stroke Rehabilitation. 2016;23(6):430- 439. 10. Cunningham R, Ward C. Evaluation of a training programme to facilitate conversation between 3. Akabogu J, Nnamani A, Otu MS, Ukoha E, Uloh- people with aphasia and their partners. Aphasiology. Bethels AC, Obiezu MN, et al. Efficacy of cognitive 2003;17(8):687-707. 344 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13872 In Silico analysis of Phospho Enolpyrovate Carboxylase gene
Noor Alwash: Researcher in the department of Biology, Faculty of Science, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
Abstract The importance of sugar in many aspects of life, such as food, health and body care products, results in its great demand all around the world. From another hand, the annual production of sugar cannot meet the increasing demand of the growing human population. Therefore, this study focused on one of the most important genes that affect the quantity of sugar production, phosphoenolpyruvate carboxylase (PEPcase). The most important crop used to extract sugar is sugarcane where sugar is stored in the stalk internodes. In this study RNA extraction was performed to produce cDNA for cloning. Sequencing the main genes using the Basic Local Alignment Search Tool (BLAST).
Keywords: RNA isolation, (PEPcase) analysis, sugar production, sequencing.
Introduction By using three sugarcane cultivars (GG, RR, RG) to isolate PEPcase gene and analyze it with the help of The average yield of stalk per year is around 60 tons bioinformatics tools. per hectare, and around 12% of the stalk contains sugar5. Materials and Methods Sugarcane is an important crap for suger and other products like fibers and ethanol. Besides its important Plant Materials products, sugar characterized with its adaptation to Three different cultivars of sugarcane, S. officinarum tropical and subtropical areas. Sugarcane is classified were selected to isolate the PEPcase gene from the leaves under the Andropogoneae tribe; it is a member of the and have been propagated in vitro using 20 different grass family, Poaceae, with maize and sorghum, as the culture media. From each cultivar 3 samples have been closest relatives6. prepared to be used with each medium from the total 20 Due to its importance for a lot of food industeris, media. sugar production does not meet the requirements. The The materials were provided by Taman Pertanian, average yield of suger is about 9 tons year2. Universiti Putra Malaysia. The three cultivars were: Sugarcane adaptation to climate conditions is due Tebu Gula (has red stem green leaves-RG), which is to the prescence of phosphoenolpyruvate carboxylase used in sugar production; Tebu Gagak (has red stem (PEPcase) enzyme. It helps the plant to uptake more red leaves-RR), which is considered to be a medicinal CO2 for photosynthesis, and therefore increasing sugar plant, and Tebu Hijau (has green stem green leaves-GG), production ratio7. which is used to extract the sugar syrup.
This study aims to understand PEPcase background Genetic Extraction and therefore find a way to increase sugar production. RNase Removal Corresponding author: Zena Faris Alwash: Two different methods were used for removing Assistant lecturer in the Collage of Pathological RNase contamination. First by rinsing the glass ware, Analysis technologies in Al-Bayan University mortar and pestle, tips, 1.5ml, 0.2ml and 10 ml tubes [email protected] in 0.1% DEPC water (Fermentas, Canada). The second Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 345 method was to autoclave at 121°C for 20 min, using an premix kit). For PCR amplification of the PEPcase gene, autoclaving machine model (Astell, UK). three different kits were used and compared, which were Promega Go Taq Flexi DNA Polymerase (Promega, RNA Extraction USA), Solis BioDyne HOT FIREPol Blend Master Three methods were applied to extract RNA from Mix (Solis, Estonia), and Intronon Biotechnology the sugarcane leaf: (Intron/Korea). There were two types of reactions from biotechnology brand, which the first is a ready to use 1. Using easy-BLUE reagent (Intron, Korea) mixture, which can be used directly to perform both cDNA synthesis and PCR reaction in one reaction 2. Geneaid Kit (Maxime RTPCR premix kit). The second type was 3. Qiagen (RNeasy Mini Kit) iTaq DNA Polymerase (Cat. No. 25021) which was set in clean sterilized (200 µl) PCR tubes to which the DNase Treatment following were added: 3 µl of 0.35 µg/µl RNA, 1 µl of RNase-free, DNase1 (Fermentas, USA) was used 10 µm forward PEPcase primer, 1 µl of 10 µm Reverse to remove the contamination of genomic DNA from the PEPcase primer, 0.25 µl of 5U/µl iTaq DNA Polymerase, RNA sample before RT-PCR. 2 µl of 10x PCR buffer, 2 µl of 2.5mM dNTP Mixture, and finally topped up to 20 µl with sterilized distilled RNA Quality Estimation water.
RNA was run on a non-denaturing agarose gel The amplification of the gene was performed in to check the RNA integrity. The gel was prepared as the PCR machine (Biometra, Germany) in 40 cycles, described in3. Initial denaturation 94° C for 2 min, the temperature of the denaturation step was 94° C for 20 sec, annealing The gel image was captured using on UV temperature was set according to primers Ta, for 20 sec, transilluminator (Bio-Rad, USA). and the extension temperature was 72° C for 30 sec. The Spectrophotometer elongation temperature was 72° C for 3 min, and then holds at 4° C. The Nanophotometer (Implen, Germany), was used to check the RNA samples quality. The primers used to amplify the PEPcase gene were optimized for a better annealing temperature. First, a Primer Design touchdown PCR was used to amplify the gene, and then a gradient PCR was used. In addition, proof reading Taq A PEPcase gene sequence was searched from the polymerase was used to increase fidelity approximately NCBI database six times more than that of Taq DNA polymerase. For (http://www.ncbi.nlm.nih.gov/) and blast was the primer concentration, different dilutions were tried performed to find the conserved region with the PEPcase to get the best result. Three different concentration of the gene sequences of other plant species. These conserved primers were used as follows: 100 pico Mole, 100 nano regions were used to design gene specific primer, by Mole, 10 µ Mole. The best was 10 µm diluted primer, using Primer 3 online software (http://bioinfo.ut.ee/ which was used for the PCR, and the best kit was from primer3-0.4.0/). Promega with proofreading Taq polymerase.
In addition, different pairs of primers (P1, P3, P4) Gel Electrophoresis of RT- Polymerase Chain from published journal were also used1. Reaction Products The amplified PCR product of PEPcase gene was separated using 1% (w/v) agarose gel Reverse Transcription Polymerase Chain Reaction at 80 volt for 40 min in 1X TBE buffer (89.0 mM Tris- (RT-PCR) base, 89.0 mM Boric acid, 2.0 mM EDTA, pH 7.5). The The Intron cDNA synthesis kit was used to synthesis DNA marker used was 1 Kb DNA Ladder GeneRuler the template cDNA strand for RT reaction (Maxime RT (Fermentas, Canada). The gel was stained with ethidium 346 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
bromide solution (0.5 g/ml) for a few seconds and Cloning Preparation then destained with distilled water. The gel image was yT & A vector from Yeastern (Yeastern, Taiwan) was captured using UV transilluminator (BioRad, USA). used to clone the PEPcase gene (Figure 1). This vector PCR Product Purification has a LacZ region where there are several restriction enzyme sites found. If the desired gene is inserted into Mega quick spin purification kit from Intron these sites then the LacZ will not be activated, and Biotechnology was used to purify the target PCR the host cell cannot hydrolyze the lactase found in the product. The purified products were sent to 1st base Sdn medium. Hence, white colonies were produced instead Bhd for sequencing using Applied Biosystems 3730xl of blue colonies, these white colonies represented the (DNA Analyzer/USA). positive colonies that contain the desired insert.
Figure 1: YT&A (2728bp) cloning vector ( Yeastern, Taiwan)
LB Medium Preparation concentration of 100 g/ml, and about 30 ml of the medium was poured into 85 mm Petri dishes, and left One liter of LB medium was prepared by mixing 10 to solidify before use. The remainder was stored at 4°C g of bacto tryptone, 5 g of bacto yeast extract and 5 g for up to one month or kept at room temperature for up of NaCl. The pH is adjusted to 7 with NaOH. Then 0.1 to one week. Then 100 l of 100 mM of IPTG and 20 M of Isopropyl b-D-1-thiogalactopyranoside (IPTG) is l of 50 mg/ml of X-Gal was spread over the LB plate prepared by dissolving 1.2 g of IPTG into distilled water which contained ampicillin and allowed to absorb for 30 and topped up to 50 ml, before sterilizing by filtration minutes at 37° C prior to use. and storing at 4°C. Then 2 ml of X-Gal is prepared by dissolving 100 mg of 5-bromo-4-chloro-3-indolyl-B- Ligation D-galactoside in 2 ml of N,N‟-dimethyl-formamide The yT&A cloning vector and PCR products were and covered with aluminum foil and stored at -20° C. centrifuged to collect the contents at the bottom of the Then 15 g agar was added to 1 liter of the LB medium tubes. The ligation buffer was vortexed vigorously and autoclaved, before allowing the culture medium to before use. cool down to 50°C. Ampicillin was added to the final Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 347
Glycerol Stock Preparation the PEPcase gene, which were stored in the refrigerator for a long time for future use by storing in glycerol stock The 80% glycerol was prepared with sterile water solution. and autoclaved, and then left until cool. 500 l of LB broth containing the transformant was added with 500 Results l glycerol in a 1.5 ml microcenterfuge tube and kept RNA Extraction at -70° C. RNA was extracted from the leaf of three sugarcane Polymerase Chain Reaction cultivars (ten individuals for each cultivar) by using three Colony PCR was performed for the screening of different kits. The quality of these products was checked the positive colonies to confirm that target gene was using Nanodrop spectrophotometer and electrophoresis. inserted into the host cell, and to obtain many copies of The results are shown in (Table 1).
Table 1: Rna extraction quantification
Kit concentration A260/A280 A260/A230
Easy blue 1.146µg/µl 1.9 1.8
Genead kit 0.026 µg/µl 1.8 1.7
Qiagen 0.35 µg/µl 2 2
RNA integrity was checked by non- denaturing agarose gel electrophoresis. RNA samples were extracted using the Qiagen kit. The other kits also gave good concentration and purity of RNA, but did not produce intact RNA.
Easy-Blue kit gave high concentration of RNA and a lysate band on electrophoresis, and Genead kit gave lower concentration of RNA and a lysate band on electrophoresis, but Qiagen kit gave good concentration of RNA and good purity (in gel electrophoresis the Qiagen band was clear and intact). Thus, Qiagen kit was selected for RNA extraction from sugarcane as it was more efficient than the other two kits (Table 2).
Table 2: gel electrophoresis of RNA isolated using Qiagen kit. Lanes (1, 2, and 3) show the intact band of rRNA isolated from GG cultivar. Lanes (4, 5, and 6) show the intact band of rRNA isolated from RG cultivar. Lanes (7, 8, and 9) show the intact band of rRNA isolated from RR cultivar.
(1, 2, and 3) show the intact band of rRNA isolated from GG cultivar. Lanes (4, 5, and 6) show the intact band of rRNA isolated from RG cultivar. Lanes (7, 8, and 9) show the intact band of rRNA isolated from RR cultivar. 348 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Primers into cDNA using reverse transcriptase polymerase chain reaction by using Intronon biotechnology kit. Three The primers used to amplify the desired gene were thousand PEPcase gene base pairs were amplified using taken from 1, as well as own primer designed in this 4 pairs of primers. The result of PCR amplification was study. Four primers were used to isolate around 3000 checked using gel electrophoresis (Figure 2). bp of PEPcase gene from the three sugarcane cultivars. PCR products with different sizes were amplified Reverse Transcriptase Polymerase Chain Reaction (ranging from 550 bp for Primer 1, 750 bp for Primer The RNA from 9 sugarcane samples which were 2 and 1000 bp Primer 4 (which is shown in Figure 2.a) isolated from three replicates of each cultivar GG- and 750 bp for Primer 3 which is shown in (Figure 2.b). PEPcase, RG-PEPcase and RR-PEPcase were converted
Figure 2: PCR products for PEPcase gene; (a) The first lane is 1 Kb marker, and Lanes: 1, 2 and 3 are GG, RG, and RR respectively for Primer 2, and lanes 4, 5 and 6 are GG, RG, and RR respectively for primer 1, and lanes 7, 8, 9, 10, and 11 are GG, GG, RG, RG and RR respectively for primer 3; (b) The first lane is 1 Kb marker, and Lanes 1, 2, 3, 4, and 5 for GG, GG, RG, RG and RR respectively for primer 4. Lane M: 1kb ladder. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 349
Cloning
After cloning and incubating the plate for 18 hours at 37° C, two types of colonies were formed white and blue (~ 35 white colonies). The white colonies were tested using colony PCR, the gel electrophoresis bands represented the gene inserted into the vector. (Figure 3)
Figure 3: Gel electrophoresis for colony PCR showing the bands of inserted PEPcase gene; (a) Bands for GG: Wells 1, 2, 4 and 5 for PEPcase 1, PEPcase 2, PEPcase 4 and PEPcase 3 respectively, and well 3 indicates for the 1Kb marker; (b) Bands for RG, the numbers are indicating the wells 2, 3, 4, 5, and 6 for PEPcase 2, PEPcase 3, PEPcase 3, PEPcase 4 and PEPcase 1 respectively, and the 1st well is indicating for the 1 Kb marker; (c) Bands for RR: the numbers are indicating the wells 1, 2, 3, and 4 for PEPcase 3, PEPcase 2, PEPcase 4 and PEPcase 1 respectively, and the 2nd well is indicating for the 1 Kb marker.
Bioinformatics Analysis 98%, 100% and 98% for GG-PEPcase, RGPEPcase and Several bioinformatics tools had been applied to RR-PEPcase, respectively, where the other matchings analyze the PEPcase gene and protein sequences. were PEPcase of Zea mays, Oryza sativia, Arabidopsis thaliana with lower query coverage percent with E-value Sequence Blast: (Basic Local Alignment Search 0.0. Tool) Disscusion The cDNA sequences of GG-PEPcase, RG- PEPcase and RR-PEPcase were subjected to blastN RNA Isolation analysis (http://blast.ncbi.nlm.nih.gov/) which searched The success of genetic study is highly dependent nucleotide query against nucleotide database. And this on the quality and quantity of the extracted genetic has revealed that there is high similarity to nucleotide material. Thus, three kits were tested to find the best for sequence of Saccharum officinarum, Saccharum hybrid, this purpose, and has been found that the best was the and Saccharum spontaneum, with query coverage percent Qiagen RNA extraction kit, which gave good quality 350 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
and quantity of RNA material with minimum amount of sugarcane. protein and carbohydrate contaminations. Furthermore, non-denaturing agarose gel electrophoresis also showed Conclusion good intact bands on the gel. Whereas the other two kits, The present research attempted to isolate and analyze Easy-blue and Genead kits either gave low concentration the phosphoenolpyruvate carboxylase (PEPcase) at the of RNA, less purity or slightly degraded RNA. genetic and protein level using in-silico analysis. The study showed that the active sites were conserved among Genetic Analysis all the cultivars studied here and this result is consistent Four pairs of primers were used to isolate 3kb of with previous studies on other C4 plants. PEPcase genes from three cultivars of Saccharum Future work officinarum (GG-PEPcase, RG-PEPcase and RRPEPcase). Primer-1, primer-2, primer-3 and primer-4 Studies in the future can focus on the reasons and were extracted at approximately 550 bp, 750 bp, 1000 bp mechanisms of the effects of PEPcase gene, this gene and 750 bp respectively using Intronon biotechnology can be isolated to be inserted into the C3 plant and kit. The isolated PEPcase genes were compared with investigate its effect on sugar productivity. the PEPcase gene sequence of Saccharum officinarum obtained from NCBI data base (http://www.ncbi.nlm. Ethical Clearance- all data has been prepared in nih.gov/), and has been found that the gene length and the department of Department of Biology, Faculty of sequence of PEPcase ORF region is almost similar, but Science, Universiti Putra Malaysia. not identical, ranging from (2635 bp - 2831 bp). While Source of Funding- self-funding. the molecular weight ranging from 810714.52 Da to 876603.37 Da, whereas the gene length and molecular Conflict of Interest - Nil. weight of SC-PEPcase are 2886 bp and 892108.55 Da respectively. There are differences in genetic level References because the PEPcase gene was extracted from different 1. Besnard G, Offmann B, Robert C, Rouch C, Cadet cultivars. F. Assessment of the C 4 phosphoenolpyruvate carboxylase gene diversity in grasses (Poaceae). The difference in gene length among Saccharum Theoretical and Applied Genetics. 2002 Aug officinarum and its cultivars led to differences in protein 1;105(2-3):404-12. sequences length and molecular weights. The protein 2. Alwash NF. ISOLATION AND IN SILICO sizes of the three cultivars ranged from (878 a.a - 961a.a) ANALYSIS OF PHOSPHOENOLPYRUVATE and the protein molecular weight ranged from (97.71 CARBOXYLASE GENE AND EFFECTS OF kDa - 105.64 kDa), whereas the protein size of SC- INDOLEACETIC ACID AND KINETIN ON PEPcase was 961a.a. and protein molecular weight was SUCROSE PRODUCTION OF SUGARCANE 108.58 kDa. (SACCHARUM OFFICINARUM, L., 1753). The PEPcase protein sequences of the three 3. Russell DW, Sambrook J. Molecular cloning: a sugarcane cultivars were almost the same as that of laboratory manual. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory; 2001. Saccharum officinarum obtained from NCBI online data base. The differences in gene length is caused by 4. Packwood K. Introduction to Proteomics, Principles mutations in the genetic level during replication. The and Applications Navin C. Mishra Foreword by result has shown clearly that these changes did not lead Guenter Blobel John Wiley and Sons, 2010, pp. 200 Print ISBN: 978‐0471754022 Online ISBN: to any critical differences in PEPcase enzyme functions, 978‐0470603871. evolutionary tree analysis and 3D model structures. Thus, these changes are considered as only minor and 5. Oloriz MI, Gil V, Rojas L, Portal O, Izquierdo Y, Jiménez E, Höfte M. Sugarcane genes differentially unimportant differences at the functional point of view4. expressed in response to Puccinia melanocephala Further investigation is required to confirm whether infection: identification and transcript profiling. these changes have any effect on sugar production from Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 351
Plant Cell Reports. 2012 May 1;31(5):955-69. 2011 Aug 10. 6. Plomion C, Bousquet J, Kole C, editors. Genetics, 7. Sage RF, Monson RK. C4 plant biology. Elsevier; genomics and breeding of conifers. CRC Press; 1998 Dec 21. 352 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13873 Hepatitis C Virus Detection In Oral Squamous Cell Carcinoma.
Noura Mohamed Kamal1; Heba Mahmoud Dahmoush2; Hend Mohammad Waguih Mahmoud Salem3 Emad S. Helmy4 1Assistant Lecturer of Oral and Maxillofacial Pathology, Faculty of Dentistry, Cairo University, Egypt., 2Professor of Oral and Maxillofacial Pathology, Faculty of Dentistry, Cairo University, Egypt., 3Basic Dental Services Department, Princess Nourah Bint Abdulrahman University, College of Dentistry, Riyadh, Saudi Arabia, 4Professor of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University, Egypt.
Abstract Background: Hepatitis C Virus infection is a major health problem causing significant morbidity and mortality worldwide. The oral cavity is one of the most frequently reported extra-hepatic disease site associated with it. It has been suggested that HCV is a possible triggering factor for precancerous and cancerous oral lesions. The aim of this study was to detect HCV core antigen in oral squamous cell carcinoma in comparison with normal mucosa tissues (control) using immunohistochemistry, to detect the possible relationship between HCV and OSCC.
Material and Methods: A total of 50 archival paraffin embedded specimens were collected (25 OSCC specimens with 25 control specimens) and HCV core antigen was evaluated by immunohistochemistry. The localization of HCV core antigen were evaluated in both groups. All cells displaying nuclear HCV core antigen immunostaining were counted.
Results: Overall frequency of HCV in OSCC cases was higher than in controls, and a highly significant difference was observed between them (p < 0.01). Correlation of HCV positivity with the characteristics of OSCC cases were noncontributory. The greatest cell count was recorded in poorly-differentiated OSCC, whereas the lowest value was recorded in control (P<0.001). Conclusion: HCV core antigen was frequently detected in OSCC. HCV is suggested to be a potential risk factor for oral squamous cell carcinoma.
Keywords: HCV core antigen, Immunohistochemistry and Oral squamous cell carcinoma.
Introduction have been implicated in the development of OSCC, the most important are cigarette smoking, alcohol Head and neck squamous cell carcinoma (HNSCC) consumption and betel-quid chewing 2. Evidences is the sixth most common cancer known worldwide suggest that viruses are involved in oral carcinogenesis with an incidence of 0.5 million new cases diagnosed and there has been a growing interest in studying this annually, around half of these cases are oral squamous correlation 3. cell carcinoma (OSCC) 1. Though numerous risk factors Hepatitis C virus (HCV) infection is a major health Corresponding author: problem causing significant morbidity and mortality Noura M.Kamal. worldwide. It is the leading cause of serious liver diseases E-mail: [email protected] as liver cirrhosis and hepatocellular carcinoma 4.Global Cell phone: 002-01003617267 disease prevalence estimated by the World Health Home telephone number: 002-0237811321 Organization (WHO) was published and indicated that Address: 79 Khatem El-Morsaleen Street, HCV virus shows 3% prevalence and it infects more Omranya, Egypt than 170 million people throughout the world 5. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 353
Egypt is considered to have the highest prevalence pathology detected. Control subjects were selected from rate worldwide 6, with 14.7% of the total population the same hospital where cases had been recruited, and showing HCV seropositivity as estimated by the Egyptian frequency matched to cases on the basis of gender, age Demographic Health Survey (EDHS) 7. Furthermore, ((±3 years). Among the controls, 14 (56%) were male HCV was detected in different organs other than the and 11(44%) female, and age ranged from 34 to 78 years liver, where the oral cavity is one of the most frequently (mean age of 55.28±11.96 years). reported extra-hepatic disease associated with HCV · Immunohistochemical procedure: infection. It has been suggested as a possible triggering 8 factor for precancerous and cancerous oral lesions . Immunostaining for EpCAM was done for all using Ventana Benchmark XT autostainer and the following The first study conducted by Nagao et al., 19959, steps occurred automatically: deparrafinization at 75°C; suggested a possible correlation of HCV with oral cavity antigen retrieval with 10mM citrate buffer, pH6.0 at cancer, since the oral cavity is frequently exposed to 130°C for 10-20 minutes; wash solution; The sections HCV from saliva and serum in HCV positive patients were then incubated in 0.3% hydrogen peroxide for 30 making the cells susceptible to genetic instability and minutes. Nonspecific protein binding was blocked through carrying the risk for oral carcinogenesis. A systematic incubation with 10% normal goat serum for 20 minutes review aimed to summarize evidence on the possible at room temperature; wash solution; treatment with relationship between HCV infection and oral cancer the primary antibody for 30 minutes (polyclonal rabbit risk has reported the presence of 10 published studies anti- HCV core antigen (HVAg), calatlog#YPA1416, investigating this correlation 10. was purchased from Chongqing Biospes Company (7F, Materials and Methods Bldg B, High-tech venture, #107 Erlang Chuangye Rd, Jiulongpo District, Chongqing, 400039, China), under · Tissue samples and case selection incubation temperature at 30°C for 44 minutes); wash -The specimens were obtained from 2 groups:- solution; Signal amplification was done by applying one drop of amplifier using the Optiview Amplification 1) Formalin fixed paraffin embedded specimens kit post-primary antibody treatment over 8 min at of 25 OSCC were retrieved from the archives of room temperature; wash solution; Secondary antibody the Oral and Maxillofacial Pathology Department, application for 30 minutes; wash solution; application Faculty of dentistry, Kasr Alini hospital. All clinical of DAB for 10 minutes at room temperature; wash and histopathological data from medical reports, were solution; counter stain with Hematoxylin for 8 minutes reviewed and data were collected. at room temperature; washing, dehydration in alcohol and xylene and mounting on glass slides by DPX. Exclusion criteria: subjects with history of smoking, alcohol consumption, or with concomitant HBV, HIV In every run positive and negative controls were infection, or with missing information on age or sex added. were excluded. Positive control: Liver tissue sample from patient Histopathological grading of the cases showed degree with chronic HCV-infection was obtained from the of differentiation to be 8 (32%) well-differentiated, 12 National Hepatology and Tropical Medicine Research (48%) moderately-differentiated, and 5 (20%) poorly- Institute (Figure.1A). differentiated. The age range was 31 years to 80 years with mean age of 55.12±12.07 years. The gender Negative control: paraffin section was stained distribution was 14(56%) males and 11(44%) females. where the primary antibody was omitted (Figure.1B).
2) Twenty five control specimens were collected as archival paraffin blocks of oral mucosal biopsies with no 354 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Figure.1 (A,B) Photomicrograph of the positive control showing strong diffuse cytoplasmic staining in hepatocytes of liver tissue sample from a chronically–infected HCV patient (x100)(A), Photomicrograph of the negative control showing negative expression in liver tissue sample from a chronically–infected HCV patient after omitting the primary antibody (x100)(B). · Assessment of immunohistochemical evaluation:
The stained sections were assessed by two methods: to statistical analysis. Statistical analysis was performed by SPSS in general (version 17). 1. Transmitted light microscopy Mean number of cells showing nuclear staining The criteria used to define antigen positive areas; obtained from the computer image analysis were were nuclear staining or combined nuclear & cytoplasmic statistically described in terms of mean value ± standard staining of tumor cells. deviation (±SD). One way ANOVA test was used to compare between the studied groups. It was followed by 2. Computer image analyzer Post Hoc multiple 2-group comparisons. All the immunostained sections were examined Numerical demographic characteristics of the HCV at magnification 40X by the image analyzer computer positive cases and HCV negative cases were compared system using the software Leica Qwin 500 (Germany) using the t-test while the chi-square test or Fisher’s exact in the Center of Research and Dental Requirements, test, as appropriate, were used in case of categorical Faculty of Dentistry, Cairo University. All cells demographic characteristics displaying nuclear HCV core antigen immunostaining were counted using a magnification x400 by light P-value was set as follows: microscopy transferred to the monitor’s screen. Five fields from each slide were examined, the mostly *P value > 0.05, non-significant. stained and highly cellular areas containing no signs **P value < 0.05, significant. of hemorrhage or necrosis were selected and counted. Mean number of nuclear counts was obtained for each ***P value ≤ 0.01, highly significant. group for statistical evaluation. Results Anti-HCV core antigen expression Statistical Analysis: Overall frequency of HCV in OSCC cases was higher All data were collected, put in tables and subjected than in controls, and a highly significant difference was Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 355 observed between them (Fisher’s exact test, p < 0.01) (Table.1).
Table 1. Statistical analysis of anti-HCV core antigen expression in control and oral squamous cell carcinoma (OSCC).
Anti HCV core antigen Control OSCC expression P-value
Positive 2(8%) 12(48%)
Negative 23(92%) 13(52%) ***P= 0.0036
Total 25(100%) 25 (100%)
***Fisher’s exact test, highly significant, � 0.01.
Anti HCV core antigen distribution (localization and pattern of expression)
Control group:
Out of 25 control samples, 23 patients showed negative expression for the antibody (Figure.2B).
Figure.2 (A,B) Photomicrograph showing negative HCV core antigen expression in control specimen from palatal tissue (x200(A). Photomicrograph showing HCV core antigen expression in control specimen from gingival tissue. Diffuse nuclear staining was noted in all layers of the epithelium in addition to granular cytoplasmic staining in the basal and parabasal layers but the superficial layer showed faint to no expression. Lymphocytes and fibroblasts in the subepithelial connective tissue showed positive staining (x200)(B). 356 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Oral squamous cell carcinoma group:
Out of 25 OSCC samples, 13 cases showed negative expression of HCV core antigen, while 12 cases showed positive expression. (Figure.3A,B)
Figure.3 (A,B); Photomicrograph showing HCV core antigen expression in a case of moderately differentiated oral squamous cell carcinoma. All neoplastic epithelial cells showed diffuse nuclear staining and granular staining in the cytoplasm. The surrounding fibroblasts and lymphocytes showed positive expression. The keratin pearls (black arrow) and apoptotic cells (black arrow head) showed negative expression (x200)(A) ; A higher maginification showing the granular staining was observed in the nuclei and nucleoli as well as the cytoplasm of the neoplastic epithelial cells (x400)(B). Clinical parameters of OSCC in association with HCV:
HCV infection was more common in male compared to female patients. In HCV positive cases, most of the patients were more than 50 years old compared with younger patients. The most commonly affected site was the buccal mucosa followed by tongue and then gingiva, while palate and floor of the mouth sites showed no expression. (Table.2).
Table.2. Statistical analysis for clinical parameters of OSCC in association with HCV.
HCV positive OSCC HCV negative OSCC Variables P-value (n=12)(%) (n=13)(%)
Gender Male(n=14) 9(64.3%) 5(35.7%) *P= 0.1107 3(27.3%) 8(72.7%) Female(n=11)
Age (years)
4(40%) 6(60%) ≤50 years(n=10) 8(53.3%) 7(46.7%) *P= 0.6882 >50 years(n=15) Mean age 56.42(SD=13.95) 53.92(SD=9.87) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 357
Site 6(85.7%) Buccal mucosa (n=7) 1(14.3%) 2(40%) Gingiva(n=5) 3(60%) 4(44.4%) Tongue(n=9) 5(55.6%) *P= 0.0970 0(0%) Palate(n=1) 1(100%) Floor of the mouth (n=3) 3(100%) 0(0%)
Pearson chi-square test, *non-significant p>0.05
HCV positivity in different histological grades of OSCC
The highest frequency of HCV infection was observed in moderately-differentiated OSCC, followed by well-differentiated OSCC and then poorly-differentiated OSCC. (Table.3) (Figur e.4A-C)
Table 3. Statistical analysis of HCV correlation with OSCC degree of differentiation. Degree of HCV positive HCV negative P-value Differentiation
Well 2 (25%) 6 (75%)
Moderate 9 (75%) 3 (25%)
**P=0.03386 Poor 1 (20%) 4 (80%)
Total 12 13
Pearson chi-square test, **significant p<0.05
Figure.4 Photomicrographs showing HCV core antigen expression in different grades of oral 358 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
squamous cell carcinoma (A-C). Well-differentiated OSCC (x200)(A), moderately differentiated OSCC (x200) (B) and poorly differentiated OSCC (x200)(C).
HCV core antigen cell count
The greatest cell count was recorded in poorly-differentiated OSCC, whereas the lowest value was recorded in control group (Table.4, Figure.5).
Table.4. HCV core antigen cell count in different grades of OSCC and control groups and significance of the difference using (ANOVA) test.
Well-differentiated Moderately- Poorly-differentiated P.O.C Control OSCC differentiated OSCC OSCC
Mean 219.8a 230.4a 353.2b 418.2c
Std Dev 19.47 17.02 10.70 27.54
Std Error 9.73 8.51 5.35 13.77
Max 248 256 342 455
Min 196 203 272 378
F value 120.910
P Value <0.0001**
*** Highly significant at p<0.01
Tukey’s post hoc test: means sharing the same superscript letter are not significantly different.
Figure.5; Column chart showing HCV core antigen cell count in all groups. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 359
Discussion in technical skills or the sensitivity of the detection methods used. Egypt is confronted with a rapidly growing HCV epidemic that distinguishes this nation from others. In the present research, our clinical data showed Hepatitis C virus is one of the principal causes of that the majority of HCV-infected OSCC cases were chronic liver disease worldwide. On the other hand; due males (64.3%) compared to female patients (27.3%). We to the paucity of specific symptoms and signs caused by believe that it could be partly allocated to the parenteral HCV, extra-hepatic manifestations among which is oral anti schistosomasis campaigns (PAT) carried out in the cancer, could represent the first signal of this infection. past, as males were found to be more affected according Furthermore, extra-hepatic tissues might act as reservoir to that reported by EDHS 7. Additionally, in our present for HCV and this may have a profound effect on HCV study, most of the HCV infected OSCC patients were transmission, morbidity and treatment. It’s claimed that more than 50 years (53.3%) old compared with younger HCV is responsible for the increase of incidence of oral patients (40%). In our opinion, the early association cancer where various studies showed that HCV might between parenteral antischistosomal campaigns (PAT) be involved in oral carcinogenesis. Nevertheless, the and HCV transmission could explain that link, although link of HCV with oral squamous cell carcinoma from this could be due to the fact that oral cancer is common the Egyptian population has not been investigated yet. among older individuals due to the prolonged exposure Therefore this study is the first to be carried out in an to oral carcinogens and other risk factors common in our attempt to detect the possible relationship between HCV population. and OSCC in Egypt. In the present study, we found that the most involved In our present study, we have detected HCV tissue in HCV positive OSCC patients was the buccal in relatively high frequency in oral squamous cell mucosa. Similarly in India, Ranka et al., 201812, also carcinoma cases. A retrospective study conducted in found that the buccal mucosa was the most common site Japan demonstrated the strong association of HCV of involvement in HCV infected OSCC patients. As far infection with the development of primary OSCC as well as we know, no other studies studied this correlation. as multiple primary carcinomas especially at sites within However the link with HCV infection should be further the upper airway and digestive tract. They reported the investigated. incidence of HCV infection in Japanese OSCC patients to be 16.7- 24% 11. In the present research, in OSCC HCV core antigen was mainly detected in the nuclei and nucleoli of all Our study was also consistent with the first study neoplastic epithelial. On the other hand, in positive liver detecting this correlation conducted in the Indian control tissue, we observed HCV core antigen to be population by Ranka et al., 2018 12, , who reported 7% localised in the cytoplasm of hepatocytes. positive immunoexpression of HCV among 100 OSCC samples and reported an obvious increase in HCV HCV is a single-stranded RNA virus and its life incidence in OSCC patients. On the other hand, certain cycle was initially considered to be restricted to the studies failed to detect this correlation such as the study cytoplasm; nonetheless, it is suggested that under certain conducted by Eftekharian et al., 2011 13, who observed circumstances, the HCV core protein can translocate into 15 a low prevalence of HCV (0.9%) in HNSCC samples the nucleus . HCV core protein is suggested to play in four different regions in Iran. Also, a nationwide, a major role in HCV pathogenesis and in contributing population-based cohort study in Denmark, found no to neoplastic transformation of hepatocytes. The core association between HCV infection and oropharyngeal can alter cellular metabolism, regulate transcription cancer development 14.Our explanation to the observed from several viral and cellular promoters, modulates 16 non- association found in other studies could be due to apoptosis, and promotes transformation . Moreover, 17 variations in the populations studied in terms of immune according to Cerutti et al., 2011 , it is also suggested status and genetic makeup of the patients. Alternatively, that the oncogenic effect of core might be associated these discrepancies could be the result of differences to its nuclear localization. In liver samples from HCV- infected patients, HCV core is located mostly in the 360 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 cytoplasm, but the truncated forms of the HCV core Source of Funding: There are no financial fundings protein were found in the nucleus in tumor tissues from to disclose HCC patients. So according to these findings, at some Ethical Clearance: Taken from Research Ethics stages of natural HCV infection, the core may localize to Committee, Faculty of Dentistry, Cairo University. the nucleus, especially in cancer patients. The interaction of core protein with the molecules of the nucleus may in References turn have an important role in the development of HCC. 1. Jithesh PV, Risk JM, Schache AG, Dhanda J, Lane This may explain why in our study we found B, Liloglou T, Shaw RJ. The epigenetic landscape nuclear localization of HCV core antigen in the OSCC of oral squamous cell carcinoma. British journal of samples rather than the cytoplasmic staining observed cancer. 2013 Feb;108(2):370-9. in the hepatocytes of the liver control tissue of the HCV 2. Petti S, Masood M, Scully C. The magnitude of chronically infected patient. Although this doesn’t tobacco smoking-betel quid chewing-alcohol explain the nuclear localisation of HCV core antigen drinking interaction effect on oral cancer in South- in the positive control tissues. Whether it is an early East Asia. A meta-analysis of observational studies. step before progression to cancer or has a different PloS one 2013;8(11). explanation. Therefore, further studies are needed to 3. Carrozzo M, Scally K. Oral manifestations of clarify the underlying molecular mechanism. In our hepatitis C virus infection. World J. Gastroenterol study, the highest frequency of HCV infection was 2014;20(24):7534. observed in moderately-differentiated OSCC (75%). 4. Mohd Hanafiah K, Groeger J, Flaxman AD, This observed result could be of mere chance, so further Wiersma ST. Global epidemiology of hepatitis studies with larger sample size are warranted to confirm C virus infection: new estimates of age‐specific or invalidate this association. antibody to HCV seroprevalence. Hepatology. 2013;57(4):1333-42. Interestingly, the greatest cell count was recorded 5. Lanini S, Easterbrook PJ, Zumla A, Ippolito G. in poorly-differentiated OSCC, which may reflect the Hepatitis C: global epidemiology and strategies increased viral load and in turn account for the aggressive for control. Clinical Microbiology and Infection. behaviour of the tumor. This hypothesis require testing 2016;22(10):833-8. in the future to indicate if HCV protein has a role in 6. Lavanchy D. Evolving epidemiology of hepatitis modulating the biological behavior of tumor cells. C virus. Clinical Microbiology and Infection. 2011;17(2):107-15. There are several limitations in the present research. Firstly, a series of large cohort could be more useful in 7. El-Zanaty F, Way A. Egypt Demographic and Health demonstrating the reported link of HCV with OSCC Survey 2008. Cairo, Egypt: Ministry of Health, El- Zanaty and Associates, and Macro International. and its parameters. Secondly, more robust technique Int Fam Plan Perspect 2009;29:158-66. such as PCR and FISH could have aided in confirming our outcomes. Nevertheless, the data are important to present and the patient groups were comparable in terms 8. Alavian SM, Mahboobi N, Mahboobi N, Karayiannis P. Oral conditions associated with of age, sex and site. hepatitis C virus infection. Saudi journal of In conclusion, the results of the present work point gastroenterology: official journal of the Saudi to an obvious increase in HCV incidence in OSCC Gastroenterology Association 2013;19(6):245. patients, suggesting a positive correlation between HCV 9. Nagao Y, Sata M, Tanikawa K, Itoh K, Kameyama and OSCC, though further studies in this regard are T. High prevalence of hepatitis C virus antibody required taking larger population into consideration. and RNA in patients with oral cancer. Journal of oral pathology & medicine 1995;24(8):354-60. The authors declare that they have no Conflict of 10. Fiorino S, Bacchi-Reggiani L, De Biase D, Interests. Fornelli A, Masetti M, Tura A, Grizzi F, Zanello M, Mastrangelo L, Lombardi R, Acquaviva G. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 361
Possible association between hepatitis C virus 14. Omland LH, Farkas DK, Jepsen P, Obel N, and malignancies different from hepatocellular Pedersen L. Hepatitis C virus infection and risk of carcinoma: A systematic review. World journal of cancer: a population-based cohort study. Clinical gastroenterology 2015;21(45):12896. epidemiology 2010;2:179. 11. Nagao Y, Sata M. High incidence of multiple 15. Suzuki R, Matsuura Y, Suzuki T, Ando A, Chiba J, primary carcinomas in HCV-infected patients with Harada S, Saito I, Miyamura T. Nuclear localization oral squamous cell carcinoma. Medical Science of the truncated hepatitis C virus core protein with Monitor 2009;15(9):CR453-9. its hydrophobic C terminus deleted. Journal of 12. Ranka R, Chaudhary M, Patil S. Prevalence of General Virology. 1995;76(1):53-61. hepatitis C virus infection in potentially malignant 16. Mahmoudvand S, Shokri S, Taherkhani R, disorders and oral squamous cell carcinoma-an Farshadpour F. Hepatitis C virus core protein immunohistochemical study. Hos Pal Med Int Jnl modulates several signaling pathways involved 2018;2(6):398-403. in hepatocellular carcinoma. World journal of 13. Eftekharian A, Khajavi M, Shokoofi S, Rahmani gastroenterology 2019;25(1):42. Z, Gachkar L, Gerami H, Rajati M, Khademi B. 17. Cerutti A, Maillard P, Minisini R, Vidalain PO, Hepatitis C virus in patients with squamous cell Roohvand F, Pecheur EI, Pirisi M, Budkowska A. carcinoma of the head and neck in Iran: is there Identification of a functional, CRM-1-dependent any relation?. European Archives of Oto-Rhino- nuclear export signal in hepatitis C virus core Laryngology 2012;269(12):2571-3. protein. PloS one 2011;6(10). 362 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13874 The Impact of Covid-19 on Migrant’s Workers Employment and Livelihood in India
Prithwiraj Swargiary, Priyambee Swargiary1, Detsung Swargiary3 1PhD Research Scholar, Department of Economics, Dibrugarh University, Dibrugarh-06, India, 2 PhD Research Scholar, Department of Economics, Dibrugarh University, Dibrugarh University, Dibrugarh-06, India, 3(former PhD Scholar), Department of folklore, Gauhati University, Guwahati-14.
The pandemic (covid-19) has adversely affected the entire world especially in terms of economic shock, labour market shock and health shock which has impacted both demand and supply. It has created an unsuitable environment by creating severe challenges amongst important sectors mainly trade, hotels, restaurant, tourism, hospitality and real estate. The worst affected are the micro small medium enterprises. Across the globe, 2.7 billion i.e. 81% of the workforce are affected by covid-19. As per International Labour Organization (ILO)93% of the world’s workers are experiencing workplace closure. The immediate effect of covid-19 on the young population has led to multiple shocks like employment and income losses, disruption in education and training etc. It has been more vulnerable to migrant workers who face constraint in both work places as well as in return to their families. Workers in the unorganized sectors especially self- employed, casual and dig workers are likely to disproportionately hit. A study by the Oxford Poverty and Human Development Initiative (OPHI) in collaboration with the United Nations Development Programme reports that more than 270 million people in India were lifted out of poverty from 2005-2016, the largest by any country. But, unfortunately measured at International Poverty Line of $ 1.90 per day covid-19 will push 71 million population into extreme poverty as per World Bank Projection of covid-19.
Index-terms: Labour Migration, Working Conditions, Remittances, Wages, Construction, Poverty, well- being
Introduction were greatly stigmatized as a carrier of the disease and to be population at risk. This had adversely affected In the past, the epidemics were hardly concerned the great contribution of migrants in economic growth, with migration and livelihood during the colonial India. innovation, skill development and enterprise in building Although major cities Mumbai, Kolkata and Chennai cities and the nation. Further, policies and programmes and many other urban places hugely suffered from small of urban development and planning in India hardly pox, plague, malaria, influenza, and cholera. (Davis launch any specific programme for the migrants. One 1951; Banthin and Dyson 1999; Hill 2011). Hill 2011 of the biggest mistakes in achieving urban sustainability stated that Mumbai experienced a deadly plague in 1896 and realizing the goals of sustainable development and also influenza in the year 1918. The epidemic of in India is the failure to recognize migrants as a stake influenza arrived in Mumbai in September 1918 which holder. Migrants workers are suffering from dual burden swept through north and east India. He found that i.e. burden of becoming poor and migrants. Due to lack the reason for excess mortality was the influenza was of identity and residential proofs the migrant’s donot negatively related with outmigration at district level receive many programmes meant for them. analysis. In the past, famine not only caused increase in mortality but also resulted in migration (Maharatna 2. Nature of the problem: 2014). BBC (2020), when migrants flee from the city, they are not only at the verge of losing their livelihood The widespread of corona virus from the China to but also at the same time they carry the infections to worldwide is mainly attributed to mobility and migration their native places. During 1980’s, when the epidemic of of people. Further, the medical professionals largely HIV/AIDS broke in various parts of the world migrants believe that the only way to control and lessen the Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 363 spread of the pandemic is through immobility, lockdown in mitigating strategy of economic and social impact of and social distancing. There has been unprecedented covid-19. breakdown of our economic and social system due to lockdown. Mostly migrant workers are most vulnerable Objective of The Study to urban disaster and epidemics. In India, the first case The specific objectives of the study have been of covid-19 was surfaced on 30TH Jan (2020), and formulated as the following: following the outbreak the lockdown was announced in the entire country on 24th march for a period of 21 days. 1] To study the employment trends in labour force Borders were sealed, schools, colleges, universities participation in India pre and post covid -19. were closed, factories, restaurant, shops transportation 2] To study the unemployment trends in India pre and all types of economic activities were shut down, and post covid-19. barring only essential services. This created a nightmare for hundreds of thousands of migrant workers, who lost 3] To analyse the impact of covid-19 on international their livelihoods overnight and became homeless. The remittances and domestic remittances. most immediate effect faced by these migrant workers were related to loss of works, wages, food, shelter, 4] To highlight the plight of migration workers in fear of getting infected and anxiety. As a result, most India. of them started fleeing from various states and cities to 5] To analyse the steps undertaken by the their native places. Many workers lost their lives either Government of India to fight against covid-19. due to hardship on the way, hunger, accident and some of them even committed suicide. Sahas (2020) reports 4. DATA SOURCES: on the basis of telephonic survey of more than 3000 The analysis has been based both on primary and migrants from north central India shows that majority of secondary sources of data. the workers were the daily wage earners and at the time of lockdown, 42% of them were left out with no ration, Analysis and Discussion one third was stuck at destinations city with no access to jobs, wages, food, shelter, 94% don’t have worker’s Migration and Livelihood: identity card. The declaration of sudden lockdown In India, millions of people adopt migration as created many difficult situations for migrants living in a livelihood strategy and they are directed towards different cities of the country. the urban centres. As per 2011 census, rural to urban Many travelers were either stuck up at stations migrants are mainly concentrated in 53 million plus urban or district borders. Further many were forced to walk agglomerations (with one million more) that comprises hundreds of miles on foot to reach their native villages 140 million out of 377 million urban population of the in the absence of public transportation. In addition, those country equivalent to 43% of the total urban population. reached their native places were seen as potential carriers A total of 53 million plus cities, out of which eight of of the covid -19 and were ill-treated by the locals. India them are mega cities with a population of 5 million and today (2020), highlighted one instance where a group of more. In India, out of 482 million workers, 194 million returnees were sprayed with chemicals to disinfect them are permanent and 15 million are semi-permanent for which later the local administration apologized. In migrant workers. the history of India, this is one of the biggest streams Employment Trends in India: of mass return migration in the country. This is a serious issue, even though they are formal citizens they A] Labour Force Participation Rate: Overall, Rural are lacking fulfillment of the economic, political and and Urban social rights. The sudden eruption of migration crisis Fig 1 : Trends in LFPR since Dec.,2019 resulting from the outbreak of covid -19, reminds us the urgency of the matter. This paper emphasizes how our understanding on migration and livelihood be helpful 364 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Source: Calculation based on CMIE CPHS Data.
In Dec 2019, the overall LFPR was 42.66%, but it remarkably fell down to 35.57% in April 2020. But it again rose to 40.33% in June 2020. In Dec 2019, the rural LFPR was 43.7% and it slightly increased to 44.1% in Jan 2020. However, there has been remarkable downfall in rural LFPR to 37.2% in April 2020 and again it rose to 41.7% in June 2020. In Dec 2019, the urban LFPR was 40.6%, but it decreased to 32.5% in April 2020 and it increased to 37.7% in June 2020.
B] Labour Force Participation Rate: Young Labour Force (15-29 yrs.)
Fig 2: Employment Trends in India: 15-29 Years Source: Calculation based on CMIE CPHS Data.
There has been a rise in young LFPR in rural area from approximately 40% in Jan 16 to 42% in July 16. But there has been a remarkable fall in young LFPR to approximately 25% in April 2020. There has been a rise in young LFPR in urban area from approximately 39% in Jan 16 to 41% in April 16. But there has been a remarkable fall in young LFPR to approximately 26% in April 2020. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 365
C] Labour Force Participation Rate: Sex Wise
Fig 3: Employment Trends in India: 15 Years and Above Source: Calculation based on CMIE CPHS Data.
A rise was witnessed in male LFPR from approximately 75% to 77% since Jan 16 to Nov 16. LFPR in male abnormally fell down to approximately 60% March 2020 and it again rose to approximately 70%. Similarly, a gradual increase can be seen in terms of female LFPR from approximately 75% to 78% since Jan 16 to July 16. A major decrease in female LFPR can be seen from approximately 62% to 55% since Jan 2020 to March 2020 and further witnessing a rise to approximately to 63% in May 2020
Unemployment Trends in India:
A] Overall, Rural and Urban:
Fig 4: Unemployment Trends in India: 15 Years and Above Source: Calculation based on CMIE CPHS Data 366 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
The overall unemployment rate was approximately 7% in Dec – 19 but it abnormally rose from approximately 8% to 24% since March 20 to May 20 and it again fell down to approximately 10% in Jun 20. The rural unemployment rate was approximately 7% in Dec – 19 but it abnormally rose from approximately 8% to 24% since March 20 to May 20 and it again fell down to approximately 10% in Jun 20. The urban unemployment rate was approximately 9% in Dec – 19 but it abnormally rose from approximately 24% to 26% since April -20 to May -20 and it again fell down to approximately 11% in Jun 20.
B] Young Labour Force:
Fig 5: Trends in UR among young labour force Source: Calculation based on CMIE CPHS Data.
The unemployment trends among young labour force was approximately 22% in Jan -16. The rate fell down to approximately 14% to 11% since May -17 to July -17. But it rose abnormally to approximately 41% in March -20 and it again fell down to 25% in May-20.
C] Male and Female:
Fig 6: Trends in Unemployment rate. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 367
Source: Calculation based on CMIE CPHS Data. A] Wages:
The unemployment trends among male was Migrant workers being part of the unorganized approximately 6% in Jan -16. The rate fell down to sector lose in bargaining for fair wages. They even lack approximately 4% to 3% since May -17 to July -17. But it minimum wages; further the agreed wages are not paid rose abnormally to approximately 24% in March -20 and on time. Even after the completion of work, substantial it again fell down to 9% in May-20. The unemployment due remains with the builders or contractors, who are trends among female was approximately 16% in Jan -16. always on the look for devouring these due wages. The rate fell down to approximately 19% to 3% since B] Working Conditions: September -16 to July -17. But it rose abnormally to approximately 20% in March -20 and it again fell down Their working conditions and hours of work are to 9% in May-20. not regulated and designed properly. They are further not paid for any excess work. They are working under Remittances: hazardous conditions. At the sites the working conditions A] International Remittance: and the facilities provided are far from satisfactory. In case of an emergency or accident there is no provision Due to covid-19, there shall be reduction in the for medical aid. flow of remittances by about 23% in 2020 to US $64 billion. A total of 82% remittances are received from C] Housing: seven countries namely United Arab Emirates [UAE], The migrant workers are provided with temporary U.S, Saudi Arabia, Qatar, Kuwait, U.K, AND Oman accommodation to adjust 2-3 people in the same room. by India. There has been sharp decrease in the flow of All the activities including food preparation, sleeping remittances in India after covid-19. Four states in India is to be done in the small space given as temporary namely Kerela, Karnataka, Maharashtra and Tamil Nadu accommodation. The accommodation being temporary, received 58.7% of total remittances. the arrangement is made with tin sheets and roofs. When B] Domestic Remittances: the temperature goes up during summer it becomes difficult for them to stay inside and during rainy season As per National Survey of Household Income & water leaks in the house and it becomes difficult for Expenditure [NSHIE] there are 11.5 million households them to stay inside the house. receiving remittances amounting to Rs 0.5 trillion in 2010-11. Households receiving remittances of 41% D] Sanitation: belong to the bottom 30% of the income distribution. The sanitation hygiene of the migrant workers house For the purpose of supporting immediate family needs and construction site is in extremely poor condition. 97% of remittances are used. Majority of them are lacking facilities such as kitchen, Plight of Migrant Workers in India: bathrooms and the toilets. There are cases of open defecation too. The environment around them is pathetic The majority of inter –district and inter-state and unhygienic. In most of the settlement availability migrants belong to the poorest section of the society of water, access to drinking water and sewage facilities and are illiterate. The mode of recruitment is through are the common problem. Majority of the workers suffer social network consisting of middlemen, contractors from clean drinking water and have to depend on open and relatives. The condition of the migrant workers is well, public water supply. There is lack of provision constantly exposed to accidents, ill health, extreme for washing clothes and utensils. Mostly they share a level of harassment and poor quality of work life. The common room along with kitchen where food is prepared workers are mostly from rural and economically lagging using the kerosene stove placed on the ground. The states like Bihar, UP, West Bengal, Chhattisgarh, MP, practice of dumping waste disposal followed by migrant Jharkhand and other states. workers has serious implications on public health and environment. 368 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
E] Electricity Supply: opportunities to this sector to move up the economic ladder. The five pillars of Atma-Nirbhar Bharat focus Majority of the migrant workers suffer from the on: provision of electricity. For lighting in night, they used candles, kerosene lamps, and battery run lights. Even, 1] Economy some having electricity connection they are subject to 2] Infrastructure frequent disconnection. 3] System F] Cooking: 4] Vibrant Demography In most of the households firewood is used as a source of cooking. They collect it from the nature as well 5] Demand. as local vendors. They are lacking proper ventilation facilities as a result huts were filled with smoke and 3] One Nation, One Ration Card: deposits of sooth resulting in potential health hazards. The Central Government had announced this scheme Schemes: in June 2019. It was initially proposed to be nationally rolled out by June 1, 2020. Now, it has been extended to 1] Aarogya Setu App 2020: be done by March 2021(Recently announced by Finance Minister). One Nation, One Ration Card Scheme helps This was adopted by the Ministry of Home Affairs the poor migrant workers to buy subsidized rice and owing to the COVID-19 pandemic to be undertaken wheat from any ration shop in the country so long as by the Central as well as State Government. This was their ration cards are linked to Aadhaar. Basically, this set up for formulating appropriate health response to scheme is all about inter-state portability of ration card. not only contains the epidemic but also to protect the As per Census 2011, 4.1crore people were inter-state health and safety of the community at large. It includes migrants and 1.4crore people migrated (intra-state) for prevention and management of the covid-19 pandemic, employment. Since, People keep moving to different contact tracing, syndromic mapping, statistical analysis, states in search of better job opportunities and higher medical research, formulation of treatment plans or standards of living, it will enable migrant and their other medical and public health responses related to family members to access Public Distribution System redressal and management of the covid-19 pandemic. (PDS)benefits from any fair shop in the country. “MeitY”, The Ministry of Electronics and Information Technology, Govt. of India has been designated as 4] Garib Kalyan Yojana: the agency responsible for the implementation of this protocol and its developers NIC, The National PM Garib Kalyan Yojana has announced by the Informatics Centre shall be responsible for collection, Central Government to help the poorer section of processing and managing response data collected by the the society during the period of Covid-19. Under PM Aarogya Setu App. Garib Kalyan Yojana, the centre announced a package of Rs.1.75 Lakh Crore and 80 Crore Indians are being 2] Atma-Nirbhar Bharat: benefitted. Under this scheme people will get five kg of wheat or five kg of rice and one kg chana every month It is the vision of the Prime Minister of India until November 2020. Women who hold Jan Dhan Narendra Modi of making India a self-reliant nation. Account will be credited with Rs.500 under this scheme. Under this programme vendors will be eligible to avail It will also be benefitted to the MNREGA workers, a working capital loan of upto Rs 10,000 with tenure health workers, senior citizens, widows and farmers. of one year and repaid monthly installments under the Ministry of Housing and Urban Affairs. No collateral 5] Migration Commission: is needed for this loan. All vendors need to do digital transactions. The scheme will help formalize the street The Covid-19 lockdown left 45-60 million migrant vendors with above objectives and will open up new labourers in the lurch across cities. Faced with lives and Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 369 livelihood challenges, a large number of them began mentioned above has not been published or submitted to leave in hordes to their native places. Migration to or accepted for publication in any form, in any other Commission links migrant workers with the state journal. We declare that we contributed significantly economy and provide them employment within the state. towards the research study, that is, conception, design The commission will identify skills of workers returning and analysis, and interpretation of data. from other states and ensure that they get jobs. Through Declaration of ownership: the Migration Commission, the government intends to provide the migrant workers guaranteed “Social This report is our original work. Security” and “Minimum Job Security”. Uttar Pradesh is the first state that introduces Migration Commission Conflict of Interest: Nil in India. Source of Funding: Self
Conclusion Ethical Clearance: This study was approved by the The study clearly indicates the plight of the institution. migration workers in India. No doubt the industry References attracts much common man that provides employment 1. Banthia J. and Dyson T. Smallpox in Nineteenth status but inside story is totally different. There are Century India, Population and Development many acts that protect and assure the quality of life of Review; 1999, Vol 25, No. 4., 649-680 pp. workers in the factories and companies, but the migration 2. BBC,2020. [cited on 6th April 2020] Available workers are completely alien to it. Long working hours, from: ttps://www.bbc.com/news/world-asia- lack of health facilities, safety measures, poor housing india-52086274. conditions, atrocities on female workers, poor wages 3. Davis, K. The Population of India and Pakistan, and inadequate compensation factors creates lots of Princeton University Press, Princeton; 1951. insecurity and hurdles for the migration workers. High 4. Hill, K. Influenza in India 1918: excess mortality incentives and good management improve productivity. reassessed: Genus; 2011, Vol. 67, No. 2, 9-29 pp. Contrary, poor working conditions, poor management 5. IndiaToday(2020).Available from: https://www. and lack of financial incentives reduces motivation of indiatoday.in/india/story/coronavirus-migrants- workers resulting in lower productivity levels. Proper sprayedwithdisinfectants-on-road-in-up-bareily- and continuous training of workers in the use of dm-assures-action-1661371-2020-03-30. contemporary building techniques is equally helpful 6. Sahas, J. Voices of the Invisible Citizens: A Rapid in improving productivity. Thus, constructive steps Assessment on the Impact of COVID-19 Lockdown must be taken by the Government and private building on Internal Migrant Workers; 2020, April, New contractors to improve the quality of life of the workers Delhi. as well as welfare measures. 7. Maharatna, A. Food Scarcity and Migration Social Acknowledgments: The authors thank the Research; 2014 Vol. 81, No. 2, 277-298 pp. anonymous referee for needful and helpful suggestions on improving the presentation of this paper. The article 370 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13875 Relationship between Procalcitonin and C-Reactive Protein on Pelod Score in Pediatric Surgery Sepsis Patients at Dr Soetomo General Hospital Surabaya
Putu Andika Rama Wismawan1, Ariandi Setiawan2, Jusak Nugraha3 1Resident of Surgery, Faculty of Medicine Universitas Airlangga /Dr. Soetomo General Hospital Surabaya, 2Staff of the Department of Surgery, Pediatric Surgery Division, Faculty of Medicine Universitas Airlangga / Dr. Soetomo General Hospital Surabaya, 3Staff of the Department of Clinical Pathology, Faculty of Medicine Universitas Airlangga /Dr. Soetomo General Hospital Surabaya
Background The incidence of sepsis in the world was estimated around 1.8 million cases / year , whereas 25-38% of them requiring treatment in intensive care unit , with mortality of 1,400 cases / day . In Indonesia, child’s mortality rate due to sepsis is still very high, around 50% -70%, and if accompanied with septic shock and multiple organs dysfunction, the rate is increased (80%) . One of the scoring system that can describe the severity degree of multiple organs dysfunction in children is PELOD (Pediatric Logistic Organ Dysfunction) score. But this assessment is time consuming, because many parameters that have to be calculated. One of the ways to shorten the time is by using diagnostic markers such as procalcitonin (PCT) and C-Reactive Protein (CRP).
Method: The research is a study of analytic observational to determine the relationship between PELOD score with a value of procalcitonin and CRP in patients of children with sepsis and determine the cutoff point of procalcitonin and CRP can be associated with incidence of septic shock. Research carried out for three months started in January 2020 until April 2020. Patients who meet the criteria for inclusion and exclusion requested approval. Laboratory blood tests were done from day 1-3 of the sepsis.
Results: In the study it was obtained the result that the age of majority is in the category of 5-10 years that as many as 11 patients (36.7%). In the category of the type of sex the most are men - men that 19 patients (63.3%) and patients mostly great suffering sepsis that 23 patients (76.7%). Analysis between CRP with PELOD Score by using the chi-square test , the obtained results that there is a relationship that significant between CRP with PELOD Sc ore on a day to 1-3 with a value of p value of each 0,001 ( p < 0,05) ; 0.002 ( p < 0.05) ; 0.004 ( p < 0.05), which means that there is significant relationship between CRP with PELOD Score . Analysis between PCT with PELOD Score by using the chi-square test , the obtained results that there is a relationship that significant between PCT with PELOD Score on a day to 1-3 with a value of p value respectively 0.005 ( p < 0,05) ; 0.001 ( p> 0.05) ; 0.016 ( p> 0.05), which means that there is a relationship which is significantly meaningful between PCT with PELOD Score. In research it obtained the value of the boundary between the groups of patients with sepsis with shock, sepsis is Pelod score value of 29 is the boundary between groups of sepsis and shock, sepsis, CRP value of 88 is the boundary between groups of sepsis and shock, sepsis, PCT value 9 is the boundary between groups of sepsis and shock sepsis .
Conclusion: There is a significant relationship between the PCT with PELOD Score and significant relationship between the CRP with PELOD Score.
Keywords: PELOD, sepsis, CRP, procalcitonin
Background immunological inflammatory process due to the body’s response to stimulation of microorganisms that triggers Sepsis is a clinical syndrome as a manifestation of an multi-organ dysfunction (MODS). The incidence of Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 371 sepsis in the world is estimated at 1.8 million cases / is inflammation by bacteria, the PCT level is always> 2 year, of which 25-38% require treatment at ICU and a ng / ml while in viral infections the PCT level is <0.5 ng mortality of 1,400 cases / day. In our country the child / ml. Several studies have stated that procalcitonin levels mortality rate due to sepsis is still high, 50% -70% and in sepsis are between 0.5-3.5 ng / ml, in severe sepsis if there is septic shock and multi-organ dysfunction, 6.2-9.1 ng / ml and in septic shock 10.8-38.5 ng / ml7. mortality increases to 80%1 The meta-analysis research also showed a significant relationship with increasing procalcitonin associated The severity of multi-organ dysfunction contributes with increased mortality8 to the increased mortality in septic patients. Prevention of status from septic children to septic shock is the key Meanwhile, CRP is an acute phase reactant that to reducing mortality in septic children. One of the is synthesized in hepatocyte which will increase if scoring systems that can describe the degree of severity there is an inflammatory process or bacterial infection. of multi-organ dysfunction syndrome in children is Under normal conditions CRP can be <8 mg / L and the PELOD (Pediatric Logistic Organ Dys-function) increases with infection. Research conducted by Wu et score. PELOD score has been validated in multicentre al. explained that an increase in CRP levels affects the studies to measure multi-organ dysfunction syndrome survival rate and mortality rate with the average CRP in children2,3,4. The PELOD score assesses function value in patients who died of 88.5 ± 22.9 mg / L being in 6 body systems, namely respiration, cardiovascular, greater than patients living 67.1 ± 17.5 mg / L6 neurological, hepatic, renal, and hematological. Leteurtre However, it is currently unclear whether the increase et al. Found that mean PELOD scores were significantly in procalcitonin and CRP is only influenced by the presence higher in patients who died at a score of 20 or more than of bacterial infection or is also influenced by multi- in patients living at scores below 20.5 So that increasing organ dysfunction caused by a systemic inflammatory the PELOD score can increase the incidence of mortality response. Some literature focuses only on the association in pediatric patients who experience sepsis. between sepsis and multi-organ dysfunction and sepsis In addition to preventing worsening of multi-organ severity score, but not many studies have looked at the dysfunction, early diagnosis of sepsis is essential to association between procalcitonin levels and multi-organ control the mortality rate for sepsis patients6. Currently, dysfunction in sepsis. In addition, there are no studies blood culture as the main standard in the diagnosis of looking for an association of increased procalcitonin and sepsis caused by bacteria has many deficiencies, including CRP with PELOD scores where PELOD is. Therefore, requiring a long examination time and sometimes not yet in this study we wanted to find out whether there is a available in all hospitals1. In addition, a positive culture relationship between increased procalcitonin and CRP result can also be because contamination factors and associated with an increase in the degree of multi-organ negative blood culture have not been able to exclude dysfunction as assessed by the PELOD score in pediatric sepsis. Because of this, various studies have been carried patients with sepsis. out to determine the faster and more accurate markers of sepsis. One of them uses diagnostic markers such Method as procalcitonin (PCT) and C-Reactive Protein (CRP) Research in the form of observational analytic according to the recommendations of the American research with prospective cohort design. Every patient College of Chest Physicians (ACCP) and the Society of who comes and is treated in the operating room Dr. Critical Care Medicine (SCCM) Consensus Conference Soetomo was determined whether it met the inclusion in 1991. and exclusion criteria. Recorded patient data includes patient identity, physical examination, and laboratory Procalcitonin is a calcitonin prohormone that is examinations, then calculating the PELOD score. Blood produced in response to endotoxin or mediators released laboratory tests are carried out regardless of the number due to bacterial infection and has a strong correlation of days treated. If someone with sepsis is found, a blood with the severity of bacterial infection. In normal sample is taken within 24 hours. circumstances, PCT levels in the blood <1 ng / ml. If there 372 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Results In this study, the results showed that the most age group was in the 5 - 10 years category, namely 11 patients (36.7%). Most of the sexes were male, namely 19 patients (63.3%) and most of the patients suffered from sepsis, namely 23 patients (76.7%).
Table 1. Characteristic of Research Subjects
Characteristics n Percentage
0-1 year old 3 10.0
1-5 years old 6 20.0
Age 6-12 years old 16 53.3
>12 years old 5 16.7
Male 19 63.3 Gender Female 11 36.7
NEC 2 6.7
Acute Appendicitis 19 63.3 Diagnosis
Acute Appendicitis with 9 30.0 Perforation
Sepsis 23 76.7 Sepsis Category Septic shock 7 23.3
In this study, it was found that most patients had is a significant relationship between CRP and PELOD CRP levels between 10 - 100 mg / l, which was 18 Score. Significantly significant between CRP and patients (60%). From these data, 11 patients (73.3%) had PELOD Score. In this study, it was found that the odds a pelod score> 100 mg / l. From these data, a correlation ratio was 21.9, meaning that someone who had a high test between CRP and PELOD Score was carried out CRP had a 21.9 x higher risk of having a PELOD score> using chi-square test, it was found that there was no 20 than those who had a low CRP. An overview of the significant relationship between CRP and PELOD Score relationship between CRP and PELOD Score can be with p value = 0.001 (p <0.05), which means that there seen in Table 2. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 373
Table 2. Relationship of CRP and PELOD Score in Day 1
PELOD
CRP Total P value OR CI Skor PELOD < 20 Skor PELOD > 20
10 - 100 mg/l 14 4 18
93.3% 26.7% 60.0%
> 100 mg/l 1 11 12
0.001 21.9 95% 6.7% 73.3% 40.0%
Total 15 15 30
100.0% 100.0% 100.0%
In this study, the cutoff point with a CRP and PELOD score> 20 days I was 99, which is the lowest limit value for patients who have PELOD score> 20.
On the first day of this study, it was found that most patients had PCT levels between> 10 ng / ml, which was 15 patients (50%). From these data, 13 patients (86.7%) had a PELOD score of> 10 ng / ml. From these data, the relationship between PCT and PELOD Score was tested using chi-square test, it was found that there was a significant relationship between PCT and PELOD Score with p value = 0.005 (p <0.05) which means that there is a significant relationship. significant between PCT and PELOD Score. In this study, it was found that the odds ratio was 8.9, meaning that someone who has a high PCT has a risk of 8.9 x higher having a PELOD score> 20 than those who have a low PCT.
Table 3. Relationship of PCT and PELOD Score in Day 1
PELOD PCT Total P Value OR CI Skor PELOD < 20 Skor PELOD > 20
0,5 – 10 ng/ml 13 2 15
86.7% 13.3% 50.0%
>10 ng/ml 2 13 15
0.001 8.9 95% 13.3% 86.7% 50.0%
Total 15 15 30
100.0% 100.0% 100.0%
In this study, it was found that the threshold value with PCT and PELOD scores> 20 days I was 12, which is the lowest threshold value for patients having PELOD score> 20. 374 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
On day 2 of this study, it was found that most Score with p value = 0.002 (p <0.05) which means that patients had CRP levels between 10 - 100 mg / l, namely there is a significant relationship between CRP and 18 patients (60%). From these data, 11 patients (73.3%) PELOD Score. In this study, it was found that the odds had a PELOD score> 100 mg / l. From these data, the ratio was 14.7, meaning that someone who had a high relationship between CRP and PELOD Score was tested CRP had a 14.7 x higher risk of having a Pelod score> on day 2 using chi-square test, it was found that there 20 than those who had a low CRP. An overview of the was a significant relationship between CRP and PELOD relationship between CRP and PELOD Score can be seen in Table 4
Table 4. Relationship of CRP and PELOD Score in Day 2
PELOD CRP Total P value OR CI Skor PELOD < 20 Skor PELOD > 20
10 - 100 mg/l 14 4 18
93.3% 26.7% 60.0%
> 100 mg/l 1 11 12 6.7% 73.3% 40.0% 0.002 14.7 95%
Total 15 15 30
100.0% 100.0% 100.0%
In this study, it was found that the threshold value with a CRP and PELOD score> 20 days II was 97.5, which is the lowest limit value for patients having PELOD score> 20.
On day 2 of this study, it was found that most patients had PCT levels> 10 ng / ml, which was 15 patients (50%). From these data, 13 patients (86.7%) had a PELOD score of> 10 ng / ml. From these data, the relationship between PCT and PELOD Score was tested using chi-square test, it was found that there was a significant relationship between PCT and PELOD Score with p value = 0.001 (p <0.05) which means that there is a significant relationship. significant between PCT and PELOD Score. In this study, it was found that the odds ratio was 12.8, meaning that someone who had a high PCT had a 12.8 x higher risk of having a PELOD score> 20 than those who had low PCT. An overview of the relationship between PCT and PELOD Score can be seen in Table 5.
Table 5. Relationship of PCT and PELOD Score in Day 2
PELOD PCT Total P Value OR CI Skor PELOD < 20 Skor PELOD > 20
0,5 – 10 ng/ml 13 2 15
86.7% 13.3% 50.0%
>10 ng/ml 2 13 15
0.001 12.8 95% 13.3% 86.7% 50.0%
Total 15 15 30
100.0% 100.0% 100.0% Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 375
In this study, it was found that the threshold value significant relationship between CRP and PELOD with PCT and PELOD scores> 20 days II was 9.75, Score with p value = 0.001 (p <0.05), which means which is the lowest limit value for patients who have that there is a significant relationship between CRP and PELOD score> 20. PELOD Score. Significantly significant between CRP and PELOD Score. In this study, it was found that the In the study on day 3, it was found that most patients odds ratio was 8, meaning that someone who had a high had CRP levels between> 100 mg / l, which was 12 CRP had a risk of 8x higher having a PELOD score> patients (40%). From these data, 9 patients (75%) had 20 than those who had a low CRP. The description of a PELOD score of> 20. From these data, a correlation the relationship between CRP and PELOD Score can be test between CRP and PELOD Score was carried out seen in Table 6. using chi-square test, it was found that there was no
Table 6. Relationship of CRP and PELOD Score in Day 3
PELOD CRP Total P value OR CI Skor PELOD < 20 Skor PELOD > 20
10 - 100 mg/l 15 3 18
83.3% 25.0% 60.0%
> 100 mg/l 3 9 12
0.001 8.0 95% 16.7% 75.0% 40.0%
Total 18 12 30
100.0% 100.0% 100.0%
In this study, it was found that the threshold value PELOD Score was tested using chi-square test, it was with a CRP and PELOD score> 20 days II was 81.5 found that there was a significant relationship between which is the lowest limit value for patients who have PCT and PELOD Score with p value = 0.006 (p <0.05), PELOD score> 20. which means that there was a significant relationship significant between PCT and PELOD Score. In this In this study, it was found that most patients had study, it was found that the odds ratio was 3.2, meaning PCT levels between 0.5 - 10 ng / ml, namely 21 patients that someone who had a high PCT had a 3.2x higher risk (70%). From these data, those who have a PELOD score> of having a PELOD score> 20 than those who had a low 20 are at PCT levels> 10, namely 7 patients (58.3%). PCT, as an illustration of the relationship between PCT From these data, the relationship between PCT and and PELOD Score can be seen in Table 7. 376 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 7. Relationship of PCT and PELOD Score in Day 3
PELOD PCT Total P Value OR CI Skor PELOD < 20 Skor PELOD > 20
0,5 – 10 ng/ml 16 5 21
88.9% 41.7% 70.0%
>10 ng/ml 2 7 9
0.006 3.2 95% 11.1% 58.3% 30.0%
Total 18 12 30
100.0% 100.0% 100.0%
In this study, it was found that the threshold value with PCT and PELOD scores> 20 days II was 9, which is the lowest limit value for patients having PELOD score> 20.
Discussion process. In this study, it was found that most of the patients had PCT levels between 0.5 - 10 ng / ml, namely Sepsis remains a major cause of morbidity and 50%. From these data, those who have a PELOD score> mortality in children. The highest incidence in infants. 20 are at PCT levels> 10, which is 50%. From these data, Sepsis is associated with extensive use of health care the results show that there is a significant relationship resources. Sepsis is the leading cause of death from between PCT and PELOD Score with p1 value = 0.001, infection, especially if it is not recognized and treated p2 value = 0.001, p3 value = 0.006 (p <0.05), which promptly. Both PCT and CRP are accepted markers of means that there is a significant relationship between sepsis. The use of CRP measures may have a decisive PCT and PELOD Score. . The results of this study are effect on the health and progress of clinical cases, in line with the research of Dewi et al.9 shows that in as it helps avoid misinterpretation and inappropriate the septic shock group, there is a significant correlation intervention, such as in sepsis. In this study, it was found between PCT and PELOD scores. that most of the patients had CRP levels between 10 - 100 mg / l and the group had CRP levels> 100 and the This study took 3 times a sample of patients with the results of the relationship test showed that there was a aim of observing the body’s response to therapy that has significant relationship between CRP and PELOD Score been given to patients whose main therapy research is on 1st, 2nd, and 3rd day with p1 value = 0.001, p2 value = surgery. From the observation of procalcitonin and CRP 0.002, p3 value = 0.001 (p <0.05) which means that there levels, the first test was obtained, namely before PCT is a significant relationship between CRP and PELOD surgery had a more significant relationship with PELOD Score. The results of this study are in line with the score, in the first 24 hours, the CRP value had a more research of Dewi et al.9 This study shows a significant meaningful relationship with PELOD score, and at the correlation between CRP and PELOD scores. third 24 hours it was obtained. CRP has a significant relationship with PELOD score. This is in line with the The PCT rate is highly correlated with the severity theory that procalcitonin is a sensitive biomarker of the score regularly used in the intensive care unit, therefore, inflammatory response and will increase in the early it can be used to determine the severity of the sepsis phase of infection. Bacterial polysaccharide cytokines Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 377 will react to trigger an immune response, in which PCT and CRP determination could be the best tool for procalcitonin is produced by thyroid cells and will determining septic activity and prognosis rather than increase rapidly in 2 to 6 hours. Meanwhile, CRP will the parameters currently used. Persistently high plasma cause a slower response than procalcitonin in the early PCT concentrations, as well as decreased PCT within phase. This is in line with the theory that CRP is useful 24 hours, are associated with a significant increase in in seeing the body’s response to given therapy and its mortality in patients with severe sepsis and septic shock. function as a marker for the diagnosis of sepsis is no The PELOD scoring system can be used to determine the better than procalcitonin. This is because the synthesis likelihood of death of a patient in a pediatric intensive of CRP in the liver takes 24 to 48 hours from the start of care unit. the infection process. Thus, in early diagnosis of sepsis, procalcitonin has an advantage over CRP. Meanwhile, Conclusion in the treatment process, to assess the body’s response There is a significant relationship between the to our therapy, the value of CRP has an advantage over relationship between PCT and CRP with PELOD Score procalcitonin. Ethical Clearance: Taken from Dr. Soetomo In the study also obtained the limit value of patients General Hospital Ethical, Research, and Development with PELOD value> 20, which means that they have a Committee. mortality risk of ≥ 50%, namely the procalcitonin value at the 9-12 level and the cCRP value at the 81.5-99 level. Source of Funding: Self In my research, I took a range value based on the limit Conflict of Interest : Nil value of the first, second, and third sampling. This limit value will determine the probability of death for the Bibliography patient. 1. Latief, A., et al. Physical Diagnosis in Children In this study, it was also found that at the initial (Second Edition). Jakarta: CV Sagung Seto; 2013. examination before surgery patients, patients with a 2. Goldstein B, Giroir B, Randolph A and the Members procalcitonin value ≥10 would have a risk of death> 50% of the International Consensus Conference on as much as 8.9 times compared to a procalcitonin value Pediatric Sepsis. 2005. Definitions for sepsis and <10. While in the first 24 hours after surgery, patients organ dysfunction in pediatrics. International with a CRP value ≥ 100 will have a risk of death> 50% pediatric sepsis consensus conference. Pediatr Crit greater 14.7x than a CRP value <100 and in the first 48 Care Med, 6, 1-8 hours after surgery patients who have a CRP value ≥100 3. Lacroix J, Cotting J. Severity of illness and organ will have a 50% risk of death 8x greater than CRP value dysfunction scoring in children. Pediatr Crit Care <100. Med, 6; 2005. pp. 126-34. 4. Metta D, Soebardja D, Hudaya D. The use of It has been observed that serum PCT and serum pediatric logistic organ dysfunction (PELOD) CRP levels increase the severity of sepsis and organ scoring system to determine the prognosis of dysfunction which can also be used to identify patients at patients in pediatric intensive care units. Pediatrica high risk for adverse outcomes. Biomarkers have proved Indonesiana; 2006. pp. 46,1-6. a suitable method for predicting clinical outcomes 5. Leteurtre S, Martinot A, Duhamel A, Proulx F, in septic patients. PCT and CRP levels are generally Grandbastien G, Cotting J et al. Validation of the measured in septic patients. PCT and CRP levels are paediatric logistic organ dysfunction (PELOD) associated with the severity of organ dysfunction, but score: prospective, observational, multicentre the concentrations are still higher than during infection. study. The Lancet, 362; 2003. pp. 192-197 This study shows a PCT value that correlates with CRP 6. Wu et al., Prognostic Value of High-Sensitivity which can help us determine whether a patient has a C-Reactive Protein, Procalcitonin and Pancreatic septic process, determine the severity of the disease and Stone Protein in Pediatric Sepsis. Medical Scine see the therapeutic response we give to these patients. monitor. China; 2017. 378 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
7. Ahmadinejad Z, Dadsetan B, Jalili M, Soudbakhsh 9. Dewi, R., Somasetia, D. H. and Risan, N. A, Rasolinejad M. Evaluation of serum procalcitonin A. ‘Procalcitonin, C-reactive protein and its in patients with systemic inflamatory response correlation with severity based on pediatric logistic syndrome with and without infection. Acta medica organ dysfunction-2 (PELOD-2) score in pediatric Iranica. 2009;47(5):583-8. sepsis’, Ajeid, 4(3); 2016. pp. 64–7. 8. Liu et al., Prognostic Value of Procalcitonin in Adult Patients with Sepsis: A Sys-tematic Review and Meta-Analysis. PLOS ONE; 2015. DOI Number: 10.37506/ijphrd.v12i1.13876 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 379 Comparison of Colonic Anastomosis Using Dry Amnion Membrane and Fibrin Glue in Intraperitoneal Infection Condition Assessed from Tissue Hydroxyproline Level Measurement (Study on Wistar Rat)
Rifqi Zulfikar1, Vicky Sumarki Budipramana2, Hartono Kahar3 1Resident of Surgery, Faculty of Medicine, Airlangga University /Dr. Soetomo General Hospital Surabaya, 2Staff of the Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Airlangga University /Dr. Soetomo General Hospital Surabaya, 3Staff of the Clinical Pathology Department, Faculty of Medicine, Airlangga University /Dr. Soetomo General Hospital Surabaya
Abstract Background : Anastomotic leak in the colon is one of the causes of high morbidity and mortality in infectious cases. The morbidity and mortality rates in patients with colonic anastomotic leakage range from 7–39%. Various efforts have been made to prevent leakage, such as changing suture techniques and using additional materials. Materials such as fibrin glue and amniotic membranes are gaining popularity in the wound healing process.
Purpose : To compare the use of dry amniotic membrane and fibrin glue in colonic anastomosis in intraperitoneal infection assessed with tissue hydroxyproline level measurement.
Method : This study is an experimental. The subjects were divided into 3 groups, group I (anastomosis using a simple interrupted suture only), group II (anastomosis and was applied with dry amniotic membrane) and group III (anastomosis using a simple interrupted sutureand was applied with fibrin glue). The anastomotic segment was taken and made into homogenate, then measured for the hydroxyproline level.
Result : The study was conducted on 27 Wistar rats, male rats that have been aged 10-12 weeks with the weight of 250-300 grams. It was obtained the differences in average levels hydroxyproline in the group I = 2157.41 (± SD = 478.60), group II = 2887.40 (± SD = 688.49) and group III = 2224.59 (± SD = 416.63). ANOVA test at hydroxyproline samples showed that P <0.05 (0.015) means that there are statistically significant differences in the levels of hydroxyproline in all three groups of samples. Post Hoc test of ANOVA showed that the levels of hydroxyproline in the group II (Interrupted suture + Dry amniotic membrane) has the most high mean difference with the significance of p<0.05 means that the levels of hydroxyproline in the group is most significant.
Conclusion : Based on the results of the study, it can be concluded that the use of the dry amniotic membrane was better than fibrin glue of colonic anastomosis in conditions of intra-peritoneal infection, there was an increase in hydroxyproline levels of colonic anastomosis tissue applied in dry amniotic membrane with statistically significant results.
Keywords : colonic anastomosis, peritonitis, fibrin glue, dry amniotic membrane, collagen, hydroxyproline
Background Corresponding Author: Rifqi Zulfikar; Anastomotic leak in the colon is one of the causes First Author; Dr. Soetomo General Hospital Surabaya; of high morbidity and mortality in infectious cases. [email protected] The morbidity and mortality rates in patients with colonic anastomotic leakage range from 7-39%. In the 380 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
case of colonic anastomotic resection accompanied by effectiveness of using the amniotic membrane can be peritonitis, the leakage rate was increased by 2.5 times1. measured by the amount of collagen in the intestinal The prevalence of anastomotic leak in the right colon tissue that is anastomosed to. This amount of collagen was lower (1.35%) than the left colon (5.20%) than all can be measured both qualitatively and quantitatively. cases of anastomotic leak in the colon2,3. A leaky colonic Measurement of the amount of collagen quantitatively anastomosis will cause the peritoneal cavity to be carried out is by measuring the hydroxyproline levels in contaminated by bacteria, causing peritonitis. One of the the tissue10. causes of leakage of a colonic anastomosis in patients On this basis, we conducted a study on Wistar rats with peritonitis is bacterial contamination of the sutures. because their intestinal anatomy and histology structure The working principle of fibrin glue in closing is similar to that of humans. The use of fibrin glue against anastomotic suture wounds is by acting as a barrier intestinal anastomoses as a wound barrier (sealant) to the wound area (sealant), where the fibrin glue will which prevents bacteria from entering the anastomotic freeze within ± 3 seconds to form a sealant, so bacteria suture, while the role of dry amniotic membrane against cannot enter the anastomose (antibacterial) suture. There anastomosis which besides having barrier properties is no external factor in this case, namely intraperitoneal (antibacterial) also has a growth factor component. It bacteria which can serve ordering fibroblasts and collagen, is against this background that this study was made, by presenting fibrin glue it is hoped that the healing this study aims to compare the effect of amniotic process involving ordering fibroblasts and collagen membrane and fibrin glue on colonic anastomoses in runs normally. It is quite expensive to use fibrin glue4. the experimental conditions of intra-peritoneal infection In the study by Senol, et al., Giving fibrin glue to a group in rats by looking at hydroxyproline levels in the of rats with peritonitis obtained significant results where anastomotic gut. in the peritonitis group treated with fibrin glue, the yield density of collagen was higher than that in the group Method 5 not given fibrin glue . However, in a study conducted This research is an experimental study on mice, by Nordentoft, et al., Giving fibrin glue did not have a because the experimental unit gets treatment. The significant effect or benefit on the anastomosis process design used is the Randomized Post Test Only Control 6 in the digestive tract . The amniotic membrane is a Group Design so that the measurement of the variable material that is widely used to help stimulate the healing is only done at the end of the study. Performed on 7 process . Wistar rats when compared to humans, these mice have similar anatomical structures of the abdomen, liver and The amniotic membrane contains components of intestines. growth factor and proteinase inhibitors8. From research, it was found that the amniotic membrane has antibacterial Rats will be divided into three groups, each with the properties, can help the process of epithelialization and same sample size. The first group (I) anastomosis used a wound healing, inhibits inflammation and scar ordering, severed knot technique (control), the second group (II) 7 and increases angiogenesis . Membrane amnions have performed anastomosis using a broken knot technique by another feature of containing large amounts of growth adding dry amniotic membrane and the third group (III) factors, cytokines, and extracellular matrix, which play performed anastomosis using a broken knot technique an important role in wound healing, and serve as a base by adding fibrin glue. The target number of mice 9 or scaffold for new tissue growth and tissue engineering . examined for each treatment was 9 mice. According to the minimum requirements of the Frederer formula. In a study conducted by Uludag, et al., The As an anticipation if there are mice that die, 2 mice are use of amniotic membranes in colonic anastomosis added for each treatment. So that a total of 33 rats were provides significant effects and benefits, where the obtained, divided into 11 rats in group I, 11 rats in group neoangiogenesis process, fibroblast activity, collagen II and 11 mice in group III. storage and hydroxyproline concentrations are higher than without the use of amniotic membranes7. The Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 381
Each mouse was assigned a number placed on divided into three groups, performed a left colon the tail. When performing actions on experimental resection at a distance of 3 cm from the peritoneal animals, operators are only given instructions by the reflection and performed anastomosis. Group I was scrambler to perform with or without amnion or fibrin anastomosed using a broken knot technique, group II glue. The scrambler was recorded without the operator’s was anastomosed by adding dry amniotic membrane knowledge. When taking the results of the seventh day, and group III was anastomosed by adding fibrin glue. the rats were sacrificed to measure the hydroxyprolin All mice were sacrificed on the 7th day, then the anastomotic segment was cut along 5 mm proximal levels of the intestinal anastomotic tissue. The operator and 5 mm distally, to check the hydroxyproline did not know whether the mice were previously given levels. The specimen was sent to the Laboratory of dry amniotic membrane or fibrin glue or not. During the Genetic Institute of Tropical Disease for tissue the examination process at the Clinical Pathology homogenate. Then sent to the clinical pathology Laboratory, the examiner was only given the mouse section for examination of hydroxyproline levels. number, but did not know whether the specimen was The data on the characteristics of the research sample are included in the group with or without amnion or fibrin as illustrated in the table below. (Table 1). It was found glue. After the results were obtained, the randomizer was that the mean age of rats in group I = 11.00 weeks (± SD recorded. From the results of recording, data analysis = 0.866), the mean age of rats in group II = 10.67 weeks was carried out. (± SD = 0.707) and the average age of rats in group III = 10.78 weeks (± SD = 0.833). Then from the data, the Results data normality test was carried out. In the normality 33 Wistar rats (Rattus norvegicus) were selected, test of the Shaphiro-Wilk test data (n <50), the research aged 10-12 weeks, weighing 250 - 300 grams. All sample data for the age of the rats had p> 0.05 (group I = rats were subjected to fecal induced peritonitis (FIP) 0.073, group II = 0.085 and group III = 0.064). 1 day before colonic anastomosis surgery. Then
Table 1. Data on the Characteristics of Research Subjects
Average Average Interrupted Average Interrupted Parameter Suture + Fibrin Glue P Value Suture (I) Interrupted Suture + Dry Amniotic Membrane (II) (III)
Age 11,00 weeks 10,67 weeks 10,78 weeks 0,675
Weight 276,67 grams 277,78 grams 277,78 grams 0,978
This indicates that the rat age data in the three sample in group III = 277 , 78 grams (± SD = 12.019). In the groups has a normal distribution. ANOVA test on sample normality test of the Shapiro-Wilk test data (n <50), the body weight shows that p> 0.05 (0.675) means that there sample data for the study’s body weight of rats had p> is no statistically significant age difference in the three 0.05 (group I = 0.618, group II = 0.586 and group III = treatment sample groups. The average body weight of 0.076). This indicates that the rat body weight data in the rats in group I = 276.67 grams (± SD = 14.142), the three sample groups have a normal distribution. ANOVA average body weight of rats in group II = 277.78 grams test on sample body weight showed that p> 0.05 (0.978) (± SD = 12.019) and the average body weight of rats means that there is no statistically significant difference in body weight in the three treatment sample groups. 382 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 2. Hydroxyproline Measurement Results
Groups Average Standard Deviation
Simple Interrupted (I) 2157,41 478,60
Simple Interrupted + Dry Amniotic Membrane (II) 2887,40 688,49
Simple Interrupted + Fibrin Glue (III) 2224,59 416,63
The average difference in hydroxyproline levels per 1 milligram of tissue was that in group I = 2157.41 (± SD = 478.60), the average hydroxyproline levels for group II = 2887.40 (± SD = 688.49) and The average hydroxyproline level for group III = 2224.59 (± SD = 416.63). In the normality test of the Shapiro-Wilk test data (n <50), the research sample data for the hydroxyproline content had p> 0.05 (group I = 0.884, group II = 0.076 and group III = 0.224). This indicates that the data on hydroxyproline levels in the three sample groups have a normal distribution. Then the statistical test used is the parametric test. ANOVA test on the hydroxyproline level of the sample showed that p <0.05 (0.015) means that there is a statistically significant difference in hydroxyproline levels in the three groups of the treatment sample.
Table 3. Post Hoc ANOVA Test
Group Intevention Mean Difference P Value
Simple Interrupted + Fibrin -67,17 0,962 Glue Simple Interrupted (I) Simple Interrupted + Dry -729,98 0,022 Amniotic Membrane
Simple Interrupted 729,98 0,022 Simple Interrupted Hydroxyproline + Dry Amniotic Levels Membrane (II) Simple Interrupted + Fibrin 662,81 0,040 Glue
Simple Interrupted 67,17 0,962 Simple Interrupted + Fibrin Glue (III) Simple Interrupted + Dry -662,81 0,040 Amniotic Membrane
Post Hoc ANOVA test showed that hydroxyproline was statistically significant. Meanwhile, the treatment levels in treatment group II (Sew Interrupted + MAK) group I (Sew Interrupted) and treatment group III (Sew had the highest Mean Difference (positive compared Interrupted + Fibrin Glue) did not have a large mean to other groups), with a significance test of p <0.05 à difference and were not statistically different (p> 0.05). meaning hydroxyproline levels in treatment group II In conclusion, treatment group II (Sew Interrupted + (Interrupted sutures + MAK) were highest and this MAK) had the highest levels of hydroxyproline and this Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 383
was statistically significant. fibroblasts and smooth muscle cells. Collagen synthesis peaks at day 5 to day 7 after intestinal anastomosis 7. Discussion In this study, administration of dry amniotic A total of 33 Wistar rats were divided into three membrane was significant in intestinal anastomosis in treatment groups, 11 in group I were anastomosed peritonitis conditions where various mechanisms of using a broken knot technique, 11 in group II were amniotic membrane action were proposed to explain the anastomosed by adding dry amniotic membrane and 11 anti-inflammatory action of the amniotic membrane, such in group III were anastomosed by adding fibrin glue. as inducing apoptosis, inhibiting chemotactic activity of One day before the operation, 33 rats were subjected to polymorphonuclear neutrophils (PMN) and macrophages. faecal induced peritonitis (FIP), after 24 hours all the rats The anti-bacterial properties of the amniotic membrane were performed laparotomy and found cloudy peritoneal are possible due to elements such as interferon, lysozyme, fluid accompanied by reddish intestines then performed transferrin, progesterone, immunoglobulin, and globulin left colon resection and anastomosis according to the B1c / B1a that are present in the amniotic membrane7. treatment group. In group I, 1 mouse died on the first The results of this study are in accordance with research day and 1 mouse died on the third day. In group II, no conducted by Uludag, et al., The use of amniotic mice died. In group III, 1 rat died on the second day. membranes in colon anastomosis provides significant Due to the limited amount of fresh lysis buffer reagent, effects and benefits, where the neoangiogenesis process, the number of mice examined is only a minimum fibroblast activity, collagen deposits and hydroxyprolin requirement. From rats living on day seven, 9 rats from concentrations are higher than without the use of group I, 9 mice from group II and 9 mice from group III amniotic membranes7. were randomly taken. On day 7, 27 rats were subjected to relaparotomy, obtained a cloudy peritoneal fluid and a Conclusion little slough that adhered to the intestinal wall, in group Based on the results of the study, it can be concluded I the intestinal part that was subjected to anastomotic that the use of the amniotic membrane provides a better resection was still incompletely dense intestinal tissue colonic anastomosis compared to the use of fibrin glue while in groups II and III intestinal tissue the anastomosis in conditions of intra-peritoneal infection, where there is done is closed completely. is an increase in hydroxyproline levels in the intestinal This study shows that the use of dry amniotic anastomotic tissue wrapped in dry amniotic membrane membranes can increase hydroxyproline levels in with statistically significant results. anastomotic tissue which correlates with an increase in Ethical Clearance: Taken from Ethical Committee the amount of collagen quantitatively because the results of Animal Research, Faculty of Veterinarian, Airlangga were statistically significant on hydroxyproline levels. University This proves that the role of dry amniotic membranes in intestinal anastomosis apart from having barrier Source of Funding: Self (antibacterial) properties7 also has a growth factor component8 While the role of fibrin glue in intestinal Conflict of Interest : Nil anastomosis is only as a wound barrier (sealant) which prevents bacteria from entering the suture. anastomosis4. Bibliography The amniotic membrane has other features, namely that 1. Bedeniuk A, Grytsenko S, Horman M, Boiko H. The it contains large amounts of growth factors, cytokines, Evaluation of Risk Factor of Anastomotic Leakage and extracellular matrix, so it plays an important role in in Patients with Colorectal Cancer Complicated by wound healing9. Small amounts of collagen will result in Ileus. Int J Surg Med. 2017;1. poor anastomotic healing thereby increasing the risk of 2. Nicolas, V. Tofik, A. Fabrice, M. Anne, C. anastomotic leakage11. The healing process for intestinal Simon, M. Jean, H. Anastomotic Leakage after anastomosis is different from the healing process in other Elective Right Versus Left Colectomy for Cancer : tissues. Collagen in the digestive tract is produced by Prevalence and Independent Risk Factor. J Am Coll Surg; 205; 2007. pp. 785-793. 384 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
3. Swayne, S. L., Brisson, B., Weese, J. S., & Sears, 7. Uludag M. Citgez B. Ozkaya O. Yetkin G. Ozcan W. Evaluating the effect of intraoperative peritoneal O. Polat N. Isgor A. Effect Of Amniotic Membrane lavage on bacterial culture in dogs with suspected On The Healing Of Normal And High-Risk Colonic septic peritonitis; 2012. pp. 971–977. Anastomosis In Rats. Int J Colorectal Dis. 24; 2009. 4. Martin, R., Sc, B. and Ph, D. ‘Special Topic The pp. 809-17. Use of Fibrin Glue in Skin Grafts and Tissue- 8. Toda A. Okabe M. Yoshida T. Nikaido T. The Engineered Skin Replacements: A Review’, Plastic Potential of Amniotic Membrane/Amnion-Derived and Reconstructive Surgery, 108, No.6; 2001. pp. Cells for Regeneration of Various Tissues. J 1713–1726. Pharmacol Sci.105; 2007. pp. 215-28. 5. Senol, M. et al. ‘The Effect of Fibrin Glue on the 9. Arrizabalaga JH. Nollert MU. Human Amniotic Intensity of Colonic Anastomosis in the Presence Membrane: A Versatile Scaffold for Tissue and Absence of Peritonitis: An Experimental Engineering. ACS Biomaterials Science & Randomized Controlled Trial on Rats’, ISRN Engineering. Vol.4(7); 2018. pp. 2226-36. Surgery; 2013. pp. 1–6. 10. Reddy GK, Enwemeka CS. A simplified method 6. Nordentoft T. Fibrin glue does nit improve healing for the analysis of hydroxyproline in biological of gastrointestinal anastomoses : a systematic tissues. Clin Biochem; 29(3); 1996. pp. 225-9. review. European Surgical Research 54; 2015. pp. 11. Ahrendt GM, Tantry US, Barbul A. Intra-abdominal 1-13. sepsis impairs colonic reparative collagen synthesis. Am J Surg 1996;171(1); 1996. pp. 102–8. DOI Number: 10.37506/ijphrd.v12i1.13877 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 385 Clinical Application of Rational-Emotive Health Education for Stress Management in Teachers
Adaobiagu N. Obiagu1, Chiedu Eseadi2, Okechukwu O. Nwaubani3, and Paul N. Onwuasoanya4 1Lecturer, Department of Social Science Education, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria, 2Lecturer, Department of Educational Foundations, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria, 3Professor, Department of Social Science Education, University of Nigeria, Nsukka, 410001, Enugu, State, Nigeria, 4Professor, Department of Educational Foundations, University of Nigeria, Nsukka, 410001, Enugu, State, Nigeria.
Abstract There is evidence that teachers encounter more stress than people in other professions. Stressors in teaching include students’ misbehaviour, excess workload, and time pressure among others. Teachers in developing countries like Nigeria encounter additional stressors outside common job stressors. Stressors peculiar to teachers in developing countries include transportation issues, cultural challenges, and delays in payment of salary. High level of stress in teaching results to health problems, burnout, absenteeism, attrition, and students’ behavioural and academic underperformance. Stress management is necessary to reduce or escape stress consequences, and rational-emotive behaviour therapy (REBT) has been widely applied to stress management and behavioural issues across contexts. This review presents the finding of a study that clinically applied Rational-Emotive Health Education Intervention (REHEI) Programme, developed from the perspective of REBT principles for stress management in teachers. The finding shows that many teachers undergo a high level of job stress and REHEI significantly reduced stress and irrational beliefs causing stress among teachers. Implications for the study for policy and future studies were pointed out.
Keywords: Clinical applications, irrational beliefs, rational-emotive behaviour therapy, rational-emotive health education, stress management, teacher stress
Introduction and the effect of clinical application of Rational-Emotive Health Education Programme (developed from the Stress is one’s response to perceived harm, threat, perspective of REBT) on stress management in teachers. or challenges. Stress (mental and physical), in most cases, is the precursor of other mental distress such Teachers play essential roles in the social-emotional as depression, anxiety, suicidal ideation, etc. It can be and cognitive development of students. But, the critical caused by lifestyle especially beliefs about and reaction roles of teachers are jeopardized by a high level of stress to challenges, threats, demands, and problems. Many among teachers. Teachers experience a higher level of people in developing countries especially African job-related stress than other professionals2,3. And stress countries encounter many threats that could cause negatively impacts personal and emotional well-being stress in their everyday lives. Aside from social issues as well as reduces performance4. In many contexts, that can induce stress, teachers in Nigeria encounter over 50% of teachers report a high level of stress5,6. In universal teachers’ job stressors and peculiar job-related Nigeria, findings have shown many teachers to report a stress. Rational-emotive behaviour therapy (REBT) high level of stress7,8. developed by Albert Ellis[1] have been widely applied The sources of stress in teaching practice is for stress management in different contexts. This context-dependent. However, existing literature shows review articulated the sources of stress in teaching, the teachers in all contexts share a number of sources of consequences of stress, the mediating role of irrational stress especially students’ disruptive behaviour9,10, beliefs on the relationship between stressors and stress, lack of administrative support2, excess workload6, 386 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
and time pressure, low students’ motivation and be functional or irrational) held by the person exhibiting value dissonance10. These teacher stressors can be a particular behaviour, stress or emotions. REBT can said to be universal teachers’ stressors having been serve as both preventive and curative medicine. It identified in various countries as stressing agents. In involves cognitive restructuring for emotional and developing countries, especially Nigeria additional and behavioural adjustment. It includes a simple ABCD peculiar teachers’ job-related stressors are identified. model with ‘A’ representing Activating Event, ‘B’ They include lack of job satisfaction8, transportation standing for Beliefs about the activating event, ‘C’ difficulties, lack of power supply, lack of opportunities representing the consequences of the beliefs about the for professional development, delay in pay7, and cultural activating event, and ‘D’ representing the Disputation or limitations such as child marriage that complicates the challenge of the beliefs20,21. REBT procedural activities needs and problems of female students. include (a) identifying the activating events, (b) identifying the beliefs held about identified activating The consequences of stress on teachers and events, (c) identifying the consequences of the identified teaching practice include mental health problems11,12, held beliefs about identified activating events, and (d) teacher burnout3, job absenteeism and attrition13, job working on self or the holder of the identified beliefs to dissatisfaction11, physical and psychological absence challenge his or beliefs by questioning and restructuring from work14, job burnout15, and impairment of students- them through understanding feels, differentiating facts teacher relationship14. Teachers’ stress also produces from opinions, and understanding self. students’ disruptive and anti-social behaviours5,16, and poor academic achievement17,18, as well as undermines A number of studies have shown REBT to be the implementation of positive behaviour interventions effective in behavioural and stress management. and supports – aimed at promoting an effective and A meta-analysis of studies on the impact of REBT healthy environment for the realization of system’s on students’ misbehaviour showed that REBT was goals – in the classroom5,17. Irrational beliefs mediate effective in reducing disruptive behaviours among the relationship between job stressors and stress them22. Aside from other professional, REBT has consequences15,19. been applied on students, parents, and teachers to help manage their relationships and produce positive Stress management is important to reduce the effect and desirable emotions, behavioural and academic of stress on teachers’ efficiency, health, and students’ outcomes in students22,23,26. Despite its usefulness in behaviour and academic performance. It involves the stress management, is has been shown that Nigerian reduction of stress or reduction if stress consequences teachers do not utilize it, but instead rely on inactive through a change of lifestyle or other procedures. Stress behavioural strategies for stress management24. These management has been pursued through various coaching stress management methods of Nigerian teachers cannot models with cognitive behavioural and rational-emotive address the problem of irrational beliefs causing stress approaches the most commonly used by practitioners. Of or solve the burnout, health or students’ performance interest to the paper is the clinical application of rational- consequences of stress. Recently, some researchers emotive behaviour therapy approach in teachers’ stress have applied REBT for stress management in Nigerian management. teachers and found it effective23,25. Presented in the RATIONAL-EMOTIVE BEHAVIOUR next section is the review of the study on the effect of THERAPY rational-emotive health education intervention (REHEI) on teachers’ stress management. Rational-emotive behaviour therapy (REBT) is a psychological model developed by Albert Ellis1 for RATIONAL-EMOTIVE HEALTH EDUCATION stress reduction and management, management and INTERVENTION PROGRAMME AND TEACHERS’ treatment of behavioural and psychological problems STRESS MANAGEMENT for promotion of healthier and happier living. Its basic Rational-emotive health education intervention assumption is that behaviours, emotions, feelings, and (REHEI) programme is a training programme with stress are the products of beliefs or thoughts (which could Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 387
therapeutic value developed by Ugwoke et al.23 and scheme, and Nigerian Empowerment Scheme recruiting clinically applied to the management of teachers’ stress additional teachers to improve students’ enrolment and irrational beliefs. The programme was based on in schools and educational performance. Findings REBT principles discussed above and aimed at helping evidencing teachers’ stress to negatively impact teachers cope with workplace stress and overcome students’ educational performance suggest the need for irrational beliefs contributing to their stress. Its contents governments’ funding of interventional programmes included cognitive-behavioural skills, therapeutic directed toward teachers’ stress management. techniques, and challenging of revealed irrational Considering the high level of stress involved in teaching beliefs about teaching. The cognitive behavioural skills practice, there is a need for a policy mandating schools involve Ellis’ ABCD model while the therapeutic to provide stress management intervention sessions and techniques include relaxation, stretching, and cognitive programmes for their teachers. restructuring. Future studies should investigate challenges The programme lasted for a period of 10-week of encountered by REBT trainers in training individuals as 20 therapeutic sessions of 60 minutes each and a 2-week well as teachers’ challenges in implementing acquired follow-up conducted after four months following the REBT skills and knowledge in different contexts. This is intervention. Participants of the study were 185 college important in African settings where religion and culture teachers (93 and 92 randomly assigned to intervention are important players in beliefs held by individuals (e.g. group and waitlist control group respectively) – out of the my colleague is diabolic; I’m having difficulties in my originally randomly sampled 470 teachers – in Southeast career as a result of my colleague’s spiritual attack, i.e. Nigeria who met the study’s inclusion criteria which are voodoo, against me, etc.). It is important to explore if teaching for up to 1 year, scoring a high level of stress traditional and religious beliefs present challenges on Teachers’ Stress Questionnaire and scoring a high to acceptance of the REBT assumptions by clients. level of irrational beliefs about teaching on Teachers’ Exploration of REBT implementation challenges could Irrational Beliefs Questionnaire used for that study. A provide insights into advancing REBT to suit contextual post-test was administered after the intervention and peculiarities. a post-post-test administered after the conduct of the 2-week follow up. Collected data were analysed and Conclusion correlated using repeated measures analysis of variance, Many teachers in Nigeria undergo stress paired t-test, partial eta squared, Mann-Whitney U test, and hold irrational beliefs about teaching with a high Mean Rank, and Pearson Product-Moment Correlation number of these teachers experiencing a high level of Coefficient. job-related stress. Rational-emotive health education intervention programme, developed from the perspective The result of the study showed that REHEI, like other of rational-emotive behaviour therapy, was effective in REBT intervention programmes, significantly reduced reducing stress and the irrational beliefs inducing them stress and irrational beliefs in teachers exposed to the in teachers. Future studies are encouraged to consider intervention while teachers in the waitlist control group possible contextual challenges that could inhibit did not report any stress reduction while also maintain teachers’ practice of the skills and knowledge acquired their irrational beliefs. This finding is consistent with from REHEI and REBT trainings. findings of other studies that show REBT to effectively 25,26 and significantly reduce stress in participants . Ethical Clearance- Not required
IMPLICATIONS AND FUTURE DIRECTION Source of Funding- Self
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Chiedu Eseadi1, Boitumelo Molebogeng Diale2,3, Vera Victor-Aigbodion4,5 , Raphael Oluwasina Babalola Folorunsho6,7, Rowland C. Uwakwe8, Paul N. Onwuasoanya9 1Lecturer, Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria, 2Associate Professor & Educational Psychologist, Department of Educational Psychology, Faculty of Education, University of Johannesburg, South Africa, 3Visiting Associate Professor, Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria, 4Postdoctoral Research Fellow, Department of Educational Psychology, Faculty of Education, University of Johannesburg, South Africa, 5Lecturer, Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria, 6Family Physician, Family Medicine Department, Tawam Hospital, United Arab Emirates, 7Adjunt Lecturer, United Arab Emirates University (UAEU), United Arab Emirates, 8Lecturer, Faculty of Education, Alex Ekwueme Federal University Ndufu-Alike Ikwo, Ebonyi State, Nigeria, 9Professor, Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria
Abstract The objective of this study was to examine the association between work irrational beliefs and each burnout dimension (physical fatigue, cognitive weariness and emotional exhaustion) by treating burnout as a construct that is multidimensional. This cross-sectional, correlational study was completed by a convenience sample of nine hundred and twenty-three Nigerian federal medical nurses. The study data were collected from participating nurses through a 15-item Nurses’ Work-related Irrational Beliefs Questionnaire (NWIBQ) and a 17-item Nurses’ Burnout Questionnaire (NBQ) with three subscales consisting of physical fatigue, cognitive weariness and emotional exhaustion. For analyses of data collected, bivariate correlation and linear regression analyses were conducted at .05 level of significance. The statistical analyses were performed using SPSS software, version 22. Results indicated that work irrational beliefs negatively correlated with physical fatigue (r=-.049, P=.136), cognitive weariness (r= -.025, P=.442) and emotional exhaustion (r=- .051, P=.123) among the nurses. The analyses also confirmed the extent of a direct association between work irrational beliefs and burnout symptoms among the nurses. Given the negative connection of work irrational beliefs with burnout among the nurses, the medical centres should ensure nurses benefit from psychological interventions to eliminate irrational beliefs and burnout issues linked to work.
Keywords: Work Irrational Beliefs; Burnout; Nigerian Nurses
Introduction behaviours, such as burnout behaviours. Irrational beliefs are hypothetical constructs in the theory of Rational Nurses holding irrational beliefs at work may Emotive Behaviour Therapy (REBT).1 Irrational demonstrate unproductive or counterproductive beliefs are regarded as the core of psychological problems because they are rigid, extreme, inconsistent Corresponding author: with reality, illogical and detrimental to individuals in Chiedu Eseadi, pursuing their fundamental life goals and purposes.2–4. Department of Educational Foundations, Faculty of David described irrational beliefs as illogical, non- Education, University of Nigeria, Nsukka, 410001, empirical, and/or non-pragmatic beliefs which generate Enugu State, Nigeria. dysfunctional consequences such as dysfunctional E-mail: [email protected] feelings, maladaptive behaviours, and unhealthy psycho- Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 391
physiological reactions.5 In the present research, work not having the energy needed to devote to relationships irrational beliefs refer to illogical thinking and beliefs with other people at work 19. Emotional exhaustion is held by nurses in relation to their nursing career. regarded as the basic individual energy component of burnout 22. Nurses holding irrational beliefs at work are likely not to be performing optimally in their duties. Significance of the Study Work irrational beliefs might make a nurse become There is a need to further understand the connection maladaptive and emotionally disturbed in the workplace. of work irrational beliefs with nurses’ burnout because This is because irrational beliefs tend to discourage prior research seemed to have combined burnout people from changing what can be changed and adjusting dimensions into a single measure in addressing this issue constructively when they cannot change the situation they 23. The use of a single measure of nurses’ burnout can are faced with 6. In the presence of negative activating pose a limitation on how much therapists and researchers events, people with high levels of irrational beliefs will would recognize the relationship of irrational beliefs develop an unhealthy negative emotional response 2,7. with each discrete dimensions of nurses’ burnout, and This is why identifying and challenging those beliefs are may invariably affect intervention efforts and theoretical key steps in the counselling process 4,6,8. advancement. Therefore, the current study aimed to Furthermore, research indicates that high irrational examine the association between work irrational beliefs beliefs could be associated with high stress and burnout and each burnout dimension (physical fatigue, cognitive 9–11. Also, high irrational beliefs are consistently weariness and emotional exhaustion) by treating burnout associated with unhealthy dysfunctional emotions such as a construct that is multidimensional. as anger and shame, and psychopathological conditions including depression, anxiety, and suicidal thoughts Methodology 12 . It is also linked to maladaptive behaviours such as This cross-sectional, correlational study was social avoidance, self-harming, procrastination, anger completed by a convenience sample of nine hundred 13 suppression, aggression, and violence . Previous and twenty-three Nigerian federal medical nurses. studies also showed that irrational beliefs result in The research ethical principles according to the WMA emotional disturbances which are often experienced Helsinki Declaration were followed in the conduct of this 14–16 alongside burnout . research. The nurses’ informed consent was obtained for their participation. The approval for this research was Burnout granted by the Faculty of Education Research Ethics Burnout is regarded as an occupational illness Committee at the University of Nigeria. prevailing among health professionals 17. In the context The study data were collected from participating of this research, burnout is described as a psychological nurses through a 15-item Nurses’ Work-related Irrational syndrome of physical fatigue, cognitive weariness Beliefs Questionnaire (NWIBQ; Cronbach α=0.90) and emotional exhaustion experienced by nurses. which is based on a four-point rating of strongly agree Shirom and colleagues stated that burnout consists of to strongly disagree, and a 17-item Nurses’ Burnout three dimensions, namely, physical fatigue, cognitive Questionnaire (NBQ) with three subscales comprising weariness, and emotional exhaustion 18,19. Physical of physical fatigue, cognitive weariness and emotional fatigue refers to an intense feeling of tiredness, lack of exhaustion and based on a five-point rating of very energy, and feeling of exhaustion which is associated often to never (NBQ first subscale, Cronbach α=0.83, with impaired physical and cognitive functioning 20. second subscale, Cronbach α =0.84, third subscale, Cognitive weariness refers to feelings of slow thinking Cronbach α=0.83) 23. Examples of the NWIBQ items and decreased mental agility 19. In addition, cognitive include: It is unbearable not to be adequately rewarded weariness refers to the lack of capacity required for the for my efforts at work, and I need the approval of my concentration and absorption of new information 21. colleagues to be able to do my work very well. Examples Emotional exhaustion refers to feeling so much weak of the NBQ items include: I feel physically drained by to demonstrate empathy to clients or coworkers and 392 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
my work (physical fatigue subscale); I have difficulty moderate association and there is no need for corrective concentrating at work (cognitive weariness subscale), measures.24 The statistical analyses were performed and I feel I am unable to be sensitive to the needs of using SPSS software, version 22. patients (emotional exhaustion subscale). Results The data were collected through the help of four The analyses of demographic data show that our research assistants over the course of three months. sample consisted of 341 males and 582 females. About For analyses of data collected, bivariate correlation 574 of the total sample were ≤ 40years old while the rest (Pearson r) and linear regression analyses were were ≥ 41years old. About 414 of the total sample had conducted at .05 level of significance. Variance inflation ≤ 10years work experience while the rest had ≥ 11years factors (VIFs) between 1 and 5 indicate that there is a work experience.
Table 1: Relationship of work irrational beliefs with burnout dimensions in nurses
NWIBQ Physical Fatigue Cognitive Weariness Emotional Exhaustion
NWIBQ 1
Physical Fatigue -.049 1
Cognitive Weariness -.025 .522** 1
Emotional Exhaustion -.051 .706** .599** 1
**. Correlation is significant at the 0.01 level (2-tailed). NWIBQ= Nurses Work-related Irrational Beliefs Questionnaire
The results in Table 1 indicate that work irrational beliefs (as measured by NWIBQ) negatively correlated with physical fatigue (r= -.049, P=.136), cognitive weariness (r= -.025, P=.442) and emotional exhaustion (r= -.051, P=.123) among the nurses
Table 2: Extent of direct connection of work irrational beliefs with dimensions of burnout among nurses
Collinearity Durbin- B SE β t Sig. 95.0% CI for B Statistics Watson Tolerance VIF
(Constant) 3.882 .023 171.218 .000 3.838 3.927
Physical Fatigue -.003 .006 -.029 -.610 .542 -.014 .008 .486 2.05 2.116
Cognitive .002 .006 .012 .297 .767 -.009 .013 .622 1.61 Weariness
Emotional -.006 .008 -.038 -.753 .452 -.021 .009 .428 2.33 Exhaustion
*Note: Unstandardized regression coefficients, SE=Standard Error for B, β =Standardized regression coefficients, CI=Confidence Interval Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 393
The results in Table 2 indicate that the connection to work. Therapists should develop and implement of work irrational beliefs (as measured by NWIBQ) with rational-emotive behaviour therapy interventions to emotional exhaustion (β= -.038, p=.452, VIF=2.33) combat work irrational beliefs and associated burnout was stronger, followed by physical fatigue (β= -.029, symptoms among nurses. p=.542, VIF=2.05) and less with cognitive weariness Limitations of this study include the use of a (β=.012, p=.767, VIF=1.61) among the nurses. These convenience sample of nurses and collection of only results confirm the extent of a direct association between quantitative data. Also, we have not ascertained the work irrational beliefs and burnout symptoms among the indirect connection of work irrational beliefs with the nurses. three aspects of nurses’ burnout. It is suggested that Discussion future research should use a combination of qualitative and quantitative measures to further understanding the We found that work irrational beliefs negatively role of work irrational beliefs in the prediction of nurses’ correlated with physical fatigue, emotional exhaustion burnout in Nigerian federal medical settings. Also, and cognitive weariness among the nurses. Our researchers should use a more robust representative results imply that the nurses’ work irrational beliefs sampling method and statistical tool to examine these are negatively linked to their burnout symptoms. Our issues among the nurses. It is also suggested that future finding supports that of 9 who found that irrational studies should consider exploring the indirect effects of beliefs accounted for a variation in burnout score. The work irrational beliefs on the three aspects of nurses’ finding of this study also agrees with that of 25 who burnout. also found that irrational beliefs accounted for a change 25 in burnout score. also noted that relationship exists Conclusion between burnout and irrational beliefs. Consistent with Work irrational beliefs negatively correlated with the present finding is that of 10 who found that there is a physical fatigue, cognitive weariness and emotional connection between irrational beliefs and high burnout. exhaustion among the nurses. Given the negative Thus, work irrational beliefs among the nurses need to connection of work irrational beliefs with burnout be tackled if significant improvements will be made in symptoms among the nurses, the medical centres should reducing their burnout symptoms. ensure nurses benefit from psychological interventions Our present research finding has some implications to eliminate irrational beliefs and burnout issues linked for burnout management in nurses as it could serve as to work. a clue to understanding the postulation of the theory Ethical Clearance- Taken from Faculty of of rational emotive behaviour therapy which states Education Research Ethics Committee at the University that stress-related problems (e.g., burnout) arise from of Nigeria. irrational beliefs. The theory also acknowledges that individuals have the capacity to alter their irrational Source of Funding- Self beliefs and experience a substantial change in their state of psychological health. Because of this, rational emotive Conflict of Interest – Nil behaviour therapy treatment often aims to uncover and alter the client’s irrational beliefs (which could result in References unhealthy negative emotions) by replacing them with 1. Ellis A. Reason and Emotion in Psychotherapy. more productive and rational beliefs. These ideologies (2nd ed.). Birch Lane Press.; 1994. can serve as the fundamental basis for the management 2. David D, Szentagotai A, Eva K, Macavei B. A of nurses’ burnout using an REBT model. Given the synopsis of rational-emotive behavior therapy negative association of work irrational beliefs with (REBT); fundamental and applied research. J Ration- burnout problem in nurses, the medical centres should Emotive Cogn-Behav Ther. 2005;23(3):175–221. ensure nurses benefit from psychological interventions 3. Ellis A, Abrams M, Abrams L. Personality to eliminate irrational beliefs and burnout issues linked Theories: Critical Perspectives. Sage; 2008. 394 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
4. Ellis A, Dryden W. The Practice of Rational Burnout in sport: A systematic review. Sport Emotive Behavior Therapy. Springer publishing Psychol. 2007;21(2):127–151. company; 2007. 16. Schaufeli W, Buunk B. Burnout: An overview of 25 5. David D. Rational–emotive behavior therapy in years of research in theorizing. In: The Handbook of the context of modern psychological research. Work and Health Psychology. In M. J. Schabracq, Published 2014. Accessed June 2, 2015. http:// J. A. M. Winnubst&C. L. Cooper(Eds.). Wiley.; albertellis.org/rebt-in-the-context-of-modern- 2003:383-425. psychological-research/ 17. Paris M, Hoge MA. Burnout in the mental health 6. Dryden W. Fundamentals of Rational Emotive workforce: A review. J Behav Health Serv Res. Therapy: A Training Handbook. London: Whurr 2010;37(4):519–528. Publishers Ltd; 2002. 18. Shirom A, Melamed S. Shirom and Melamed 7. Madewell J, Shaughnessy MF. An Interview with Burnout Questionnaire. Published 2005. Accessed Judith Beck About Cognitive Therapy: Judith August 30, 2017. http://www.shirom.org/arie/ Beck. North Am J Psychol. 2009;11(1):29-36. index.html 8. Ellis A, Blau S. The Albert Ellis Reader: A Guide 19. Shirom A, Melamed S, Toker S, Berliner S, Shapira I. to Well-Being Using Rational Emotive Behavior Burnout and health review: Current knowledge and Therapy. Citadel Press; 1998. future research directions. In: International Review 9. Balevre PS, Cassells J, Buzaianu E. Professional of Industrial and Organizational Psychology. Vol nursing burnout and irrational thinking: a replication 20. Consulting Psychologists Press; :269-309. study. J Nurses Prof Dev. 2012;28(1):2–8. 20. Shen J, Barbera J, Shapiro CM. Distinguishing 10. Bermejo-Toro L, Prieto-Ursúa M. Teachers’ sleepiness and fatigue: focus on definition and irrational beliefs and their relationship to distress measurement. Sleep Med Rev. 2006;10(1):63–76. in the profession. Psychol Spain. 2006;10(1):88-96. 21. Marais C, Mostert K, Rothmann S. The 11. Meehan K. Examining the relationship between psychometrical properties of translated versions of irrational beliefs, rational emotive coping the Maslach Burnout Inventory-General Survey. strategies, and teacher burnout. Published online SA J Ind Psychol. 2009;35(1):175–182. 2011. 22. Maslach C, Schaufeli WB, Leiter MP. Job burnout. 12. Browne C, Dowd E, Freeman A. Rational and Annu Rev Psychol. 2001;52(1):397–422. irrational beliefs and psychopathology. In: Rational 23. Eseadi C. Career Satisfaction, work-related and Irrational Beliefs in Human Functioning and irrational beliefs and demographic variables as Disturbances: Implications for Research, Theory, predictors of work stress and burnout among nurses and Practice. Oxford University Press; 2010:149- in Federal Medical Centres in South-East Nigeria. 171. Doctoral Thesis, University of Nigeria, 2019. 13. Szentagotai A, Jones J. The behavioral consequences 24. Frost J. Multicollinearity in Regression Analysis: of irrational beliefs. In: Rational and Irrational Problems, Detection, and Solutions. Published Beliefs in Human Functioning and Disturbances. 2017. Accessed February 2, 2020. https:// In D. David, S. J. Lynn&A.Ellis (Eds.). Oxford statisticsbyjim.com/regression/multicollinearity- University Press.; 2010:75-97. in-regression-analysis/ 14. Cresswell SL, Eklund RC. Changes in athlete 25. Turner M, Moore M. Irrational beliefs predict burnout over a thirty-week “rugby year.” J Sci Med increased emotional and physical exhaustion Sport. 2006;9(1-2):125–134. in Gaelic football athletes. Int J Sport Psychol. 15. Goodger K, Gorely T, Lavallee D, Harwood C. 2016;47(2):187–201. DOI Number: 10.37506/ijphrd.v12i1.13879 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 395 Developing Clinical Preceptor Protocol In Clinical Teaching For Nursing Profession Students at General Hospital Dr. Pirngadi Kota Medan, Indonesia
Rispalina1, Dewi Elizadiani Suza2, Nurmaini3 1Master Student, Faculty of Nursing, Universitas Sumatera Utara, Indonesia, 2 Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Indonesia, 3Lecturer, Faculty of Public Health, Universitas Sumatera Utara, Indonesia
Abstract Objects: to develop clinical preceptor protocol in clinical teaching for nursing professional students.
Methods: the study was an action research approach. Seventeen were participants as a clinical preceptor. Data were collected by focus group discussion and clinical preceptor knowledge questionnaire related to the role of clinical preceptors in the clinical learning of nursing profession students. Data were analyzed using descriptive statistics and analysis content.
Results: the study appeared the theme of knowledge about clinical preceptors in clinical learning of nursing profession students namely: supporting factors to claim as a teaching hospital; the role of clinical preceptors in providing clinical learning; and the expectations of clinical receptors in carrying out their duties as a clinical preceptor. This study produced a protocol that was able to increase clinical preceptor knowledge in providing clinical learning to nursing professional students with a frequency of 70.59% to 88.23%.
Conclusion: the existence of a hospital that facilitates the protocol which is used as a reference for clinical learning is expected to be a support and reward in carrying out its role as a clinical preceptor for nursing professional students.
Keywords: Clinical preceptors; Clinical learning; Nursing profession; Protocol
Introduction Ericson and Zimmerman found that the perceptions of clinical preceptors about nurse student practice readiness Clinical learning is a real education to educate are not by the readiness of their own practical skills, students to apply the results of the academic learning as clinical preceptors assist in providing knowledge, process so that the ability of clinical preceptors is needed increasing skill competencies in meeting the needs to support the learning process(1). Clinical learning is of nursing students in professional practice, patient used to strengthen all competencies to apply theoretical management, skills further according to a licensed knowledge, concepts, and technical skills where students educational curriculum so that nursing students are ready are directly guided by a clinical preceptor who can help to be trained to increase knowledge, self-confidence, and reduce stress for nursing professional students as nursing be able to provide care inpatient care(4). graduates who are new to the field of work(2). The study by Vuckovic, Karlsson, and Charlotta said Clinical preceptors in the learning process are a that the point of view of a clinical preceptor and student model that is widely used in the nursing process to help nurse is necessary to create a comfortable learning students transition from a beginner level to a clinical environment and provide opportunities to practice professional role, in applying basic level knowledge and independently to gain experience and knowledge in skills needed in the nursing profession(3). The study by caring for patients, a thing that is often difficult by 396 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 nursing students because they often perceive clinical collection had four stages: reconnaissance, planning, learning as troublesome due to lack of knowledge and acting and observing, and reflection. Data were analyzed skills, especially poor communication with clinical using descriptive statistics and analysis content. The preceptors(5). principles of trustworthiness were applied to ensure the rigor of the study Methods Results The study was used as a qualitative study with an action research approach. The participants were 17 Reconnaissance using purposive sampling, Inclusion criteria: 1) having a The results of data collection at the reconnaissance nursing profession as a minimum education; 2) having a stage were grouped into four parts, namely: 1) knowledge nurse’s license, work permit and, competency certificate of clinical preceptors in clinical learning of nursing according to expertise; 3) head of room/inpatient team professional students at Dr. Pirngadi hospital Medan; with clinical nurses (PK III); 4) having at least two 2) supporting factors to declare Dr. Pirngadi hospital consecutive years experiences as a clinical preceptor; Medan as an educational hospital; 3) the role of clinical 5) has been recognized by the hospital as a clinical preceptors in providing clinical learning for nursing instructor/clinical preceptor. Data were collected by profession students in hospitals, and 4) the expectations focus group discussion, observation, self-report, and of clinical preceptors in carrying out their duties as field notes. The researcher’s data collection tools used clinical preceptors in hospitals. voice recorders, Focus Group Discussion (FGD) guides, and knowledge questionnaire and field notes. Data
Table1. knowledge about clinical preceptor protocol at Dr. Pirngadi hospital Medan
No. Knowledge f %
1 Good 12 70.59
2 Sufficient 3 17.65
3 Less 2 11.76
Total 17 100
Table1. show that knowledge of clinical preceptors and applying clinical preceptor protocols. Thus the about clinical preceptors with the measurement results clinical preceptor protocol in the hospital can become obtained with good knowledge, namely 12 people a guideline for clinical receptors in providing clinical (70.59%), sufficient knowledge, namely 3 people learning for nursing profession students by involving (17.65%), and less knowledgeable, namely 2 people three experts who have an understanding of clinical (11.76%) ). preceptors.
Planning Acting and Observing
The planning stage was planning a meeting with Held a meeting with hospital management to the hospital management regarding the formation of a discuss the preparation of clinical preceptor protocols; to clinical preceptor protocol formulating a team, planning discuss tentatively a revised clinical preceptor protocol tentative protocols, planning protocol outreach activities, draft according to suggestions and input from nursing management and a protocol socialization plan; forming Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 397 a clinical preceptor protocol formulation team and goals, and the delegation of authority by a clinical disseminating information related to the implementation preceptor. The clinical preceptors can carry out their role of the clinical preceptor protocol activities; heads of and, function as a clinical preceptor. rooms; team heads; nursing supervisors in socialization Outcomes of action research activities. Socialization was carried out by distributing material about clinical preceptor protocols. During a) The impact of implementing the clinical the implementation of the clinical preceptor protocol, preceptor protocol was seen in the results of the FGD the researchers also made several revisions to the conducted on participants at the FGD reflection stage clinical preceptor protocol which was discussed with resulting in three themes, namely: the benefits that clinical preceptors. In this stage, researchers observed participants received during the implementation of clinical preceptor protocol trials carried out by clinical the clinical preceptor protocol; the weaknesses that preceptors to nursing professional students who are participants obtained during the implementation of the carrying out clinical practice after the socialization of clinical preceptor protocol; and the factors supporting clinical preceptor protocols at the Hospital. participants running the clinical preceptor protocol.
Reflecting b) Increased clinical preceptor knowledge about clinical preceptor protocols. The results of the data In the reflecting activity, namely FGD to explore obtained at the reflection stage through self-report the understanding of participants’ perceptions before measurement of clinical preceptor knowledge after and after the implementation of the clinical preceptor the implementation of the clinical preceptor protocol protocol formulation, after the trial results used the then increased the knowledge of clinical preceptors to clinical preceptor protocol, this protocol was used 88.23%. as a guide in providing clinical learning for nursing professional students, easy to carry out their roles and Table2. knowledge of clinical receptors about duties. There is a distinct satisfaction felt by clinical clinical preceptor protocols at Dr. Pirngadi Hospital receptors because their desire is contained in the clinical Medan preceptor protocol that has been established, to re-deploy the clinical preceptor protocol knowledge questionnaire. Knowledge
Based on the results of the analysis of the frequency Categoric Before After distribution data, the level of clinical preceptor knowledge about the clinical preceptor protocol, the f % f % results showed an increase in good knowledge to 88.23% and sufficient knowledge to increase to 11.77%. Good 12 70.59 15 88.23 Looking for information on inhibiting and supporting Sufficient 3 17.65 2 11.77 factors during the process of clinical preceptor activity, i.e. after trials using updated clinical receptor protocols, Less 2 11.76 0 0 clinical receptors have inhibitions if clinical receptors do not actually use clinical receptor protocols, where Total 17 100 17 100 clinical receptors have so much work apart from being a clinical preceptor. The results of the percentage of knowledge of clinical They also have jobs as head of the room, orphanage, preceptors in the reconnaissance stage of the clinical and nurse executives. Factors Supporting Participants preceptor protocol for 17 clinical receptors, there were Running the Clinical Preceptor Protocol, that is, 70.59% good knowledge; 17.65% sufficient knowledge; according to participants, after the trial using a clinical and 11.77% less knowledge. At the reflection stage, preceptor protocol that has been established by clinical the results obtained were 88.23% good knowledge; preceptors because in the protocols that have been and 11.76% sufficient knowledge. This explains that established there is the meaning of clinical preceptors, the level of clinical preceptor knowledge about clinical 398 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
preceptor protocols at Dr. Pirngadi hospital Medan has namely, guidance activities are discussed earlier, an increasing reflection stage. receptors and unit managers with sufficient knowledge to fulfill the nursing professional learning, and hospitals Discussions are good clinical learning vehicles. as well as having (12) At the reconnaissance stage, the researcher found inter-professional relationships in the clinical area . the problem that the clinical preceptors who provide Research by Kamolo, Vernon, and, Toffoli states clinical learning to nursing professional students do not that after the development of interventions in clinical have regulations such as fixed protocols/guidelines, the preceptors, changes in knowledge, skills, and attitudes in (13) minimal number of clinical preceptors for Nurse students learning are the most frequently reported outcomes . who can play their role as role models, awaken student According to the results of research by Dahlke abilities, invite to think critically, as well as carrying out et al., it was found that the insights from clinical good socialization, the competence of clinical preceptors preceptors and academic preceptors play an important that are not the same in providing learning in clinical role in influencing the clinical learning process and practice vehicles, lack of confidence in carrying out cannot be separated from the ability of the preceptors to their role as clinical preceptors, a collaboration between communicate and create a comfortable clinical learning academic and clinical receptors that has not been vehicle(14). According to Vuckovic, Karlsson, and, running well, the high workload of clinical preceptors Charlotta from the perspective of a clinical preceptor who are also implementing nurses, as well as limited and nursing student that in the clinical learning facilities and infrastructure in supporting the clinical process it is necessary to create a comfortable learning learning process, this causes clinical learning of Nurse environment and provide opportunities for independent professional students to run ineffective(6). practice to gain experience and knowledge in caring for This statement is in line with Mingpun, Srisa- patients, things that are often considered difficult by ard, and Jumpamool, namely guiding nursing students nursing students because they often perceive clinical and nurse students to learn to apply their theories learning as troublesome due to a lack of knowledge and knowledge(7). The study of learning for a clinical and skills, especially poor communication with clinical (5) receptor shows that the competence of clinical receptors preceptors . will be more effective if they receive preparation for Conclusions their own role(8) and clinical receptors require additional information about the requirements for conducting a In this action research study, a clinical preceptor final evaluation during the learning process(9). protocol was produced to support the uniformity of science in providing clinical learning to Ners Approach efforts made in clinical preceptor activities professional students, the hospital to facilitate each are establishing relationships one by one, learning clinical receptor by providing clinical preceptor training, independently, creating a safe environment for reflection facilitating clinical receptors to improve their education, and critical thinking, providing advice, counseling, and facilitating protocols that can be used by clinical guidance, providing strength, and constructive feedback. receptors in guiding Ners professional students. However, clinical preceptor activities are widely used in the formal process by helping nursing students to gain Conflict of Interest: Nil initial practical competence through direct supervision in Source of Funding: No funding in this is a study a short time(10). The competencies that clinical preceptors must have to be able to facilitate students in the clinical Ethical Consideration: This research has passed the learning process are competence as a professional nurse, test of ethics from the health research ethics committee competence in fostering interpersonal relationships, of the Nursing Faculty of Universitas Sumatera Utara, (11) competence in teaching, and managerial abilities . with registration number 1873/III/SP/2019. Research by Cloete and Jeggels states that the factors that influence clinical preceptors are positive, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 399
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Rofina Sari Jefrianda1, Ridha Dharmajaya2, Rosina Tarigan3 1 Master Program, Faculty of Nursing, Universitas Sumatera Utara, Medan, Indonesia, 2 Lecturer, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia, 3 Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Medan, Indonesia
Abstract Objects: To analyze changes in consciousness level and blood pressure of acute stoke patients administering mannitol therapy.
Methods: The study was a descriptive cohort. Thirty-four respondents were applied to selecting by purposive sampling. Data were analyzed by descriptive.
Results: The results showed that there was an improvement in consciousness level (GCS). The improvement in the patient’s level of consciousness occurred after more than twenty-four hours of getting mannitol therapy. While the blood pressure until the third day, there were still suffering from hypertension.
Conclusion: Improvements in consciousness level after administering mannitol therapy indicate loss of cerebral edema, improvement in cerebral blood flow (CBF) and brain perfusion pressure (CPP), and repair of damaged nerve cells.
Keywords: Hemorrhagic stroke, Acute phase, Cerebral edema, Mannitol therapy
Introduction In Southeast Asia, there are around 13 million new strokes annually, of which around 4.4 million die Stroke is one of the causes of brain disorders at the within 12 months(3). In 2020, an estimated 7.6 million peak of productive age, which is the biggest threat to people will die from stroke(1). The prevalence of stroke cause disability in human life and is the second leading in Indonesia has increased from 2007 (3.8%) to 2013 cause of death after heart disease in most countries in (12.1%). In absolute terms, the number of Indonesians the world(1). In 2012, approximately 10% of all deaths who suffer from a stroke is around 3 million. The worldwide, and about 4% of disabilities of all ages province with the highest stroke prevalence tendency is were due to strokes. The American Heart Association South Sulawesi, compared to other provinces (17.9%), reports that one person has a stroke every 40 seconds and Riau province is the lowest (5.2%). In the province and one person dies every 4 minutes in America with of North Sumatra in 2013, the estimated stroke sufferer a prevalence of 2.8% which is expected to increase by aged grater then 15 years is one thousand people(4). 21.9% in 2030(2). In addition to causing a high number of deaths, the disability rate due to stroke reaches 65% and is the third cause of physical paralysis in the world with an Corresponding author: increase of 19%(5). The duration of treatment, the delay Rofina Sari Jefrianda in healing, and the presence of persistent neurological E-mail: [email protected] sequelae will all result in decreased productivity. Jalan Prof. Maas No.03, Kampus USU, Medan 20155, Sumatera Utara, Indonesia A stroke consists of a series of processes starting with Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 401
the rupture of brain blood vessels causing blood to leak participation to ensure patient safety(12). Nurses play an into the brain parenchyma tissue, the cerebrospinal fluid important role in the patient’s treatment process. The role spaces around the brain, or a combination of both. At the of nurses in administering drug therapy is to carry out the onset of a stroke within a few minutes to several hours, nursing process which consists of assessment, planning, cytotoxic edema occurs then develops into vasogenic implementation, and evaluation/monitoring(13). edema due to the displacement of intravascular fluid into Monitoring is one of the key elements of nurses in the interstitial space(6). treatment in the first 72 hours of acute stroke(14). One The onset of death within seven days in stroke of the aspects that need to be monitored is neurological patients was 31%(7). The hemorrhagic stroke mortality status and vital signs. Neurologic status and vital rate was 27-52% and the majority died immediately after signs should be observed and recorded accurately to the onset of bleeding, but it can also cause disability. monitor signs of neurological damage, stability, and The mortality of hemorrhagic stroke patients in the first improvement. week was 11 (55%) deaths and 18 (90%) within two weeks after being hospitalized out of a total of twenty Methods people who died at the Bahrain Royal Medical hospital The study was a descriptive cohort. The study was (8) in the Kingdom of Bahrain . carried out at Adam Malik and Dr. Pirngadi Hospital from January to March 2018. Thirty-four respondents Many factors cause death in acute phase stroke were involved using purposive sampling. Inclusion patients. Based on the research and theory found, it is criteria: 1) patients with a diagnosis of hemorrhagic stated that some of the causes of death in stroke patients stroke confirmed by clinical examination and head are cerebral edema (edema perihematomal develops CT scan; 2) in the acute phase less than 72 hours; 3) shortly after intra-cerebral bleeding occurs, and peaks receiving mannitol therapy, and 4) willing to become a few days later), pulmonary embolism, aspiration respondents. Exclusion criteria: 1) having a history of pneumonia/infection, heart defects, hydrocephalus and neurological disorders; 2) being in a chronic phase; 3) deep vein thrombosis(9). patients who died less than 72 hours (acute phase); and One of the therapies used in patients with 4) patients who received mannitol therapy more than 3 hemorrhagic stroke is Osmotherapy (hyperosmolar days after a stroke attack. therapy) using the mannitol osmotic agent. Mannitol is The level of consciousness was examined using an osmotic diuretic agent that has been used for decades the Glasgow coma scale (GCS) developed in Glasgow, to reduce intracranial pressure due to cerebral edema. Scotland in 1974 by Teasdale and Jennett. The GCS The results of this study were supported by a research is a scale that is widely used as a semi-quantitative report published by Asghari et al. which concluded clinical measurement of the level of consciousness that the GCS value increased slowly after mannitol based on eye open conditions, the patient’s verbal and administration(10). The increase occurred at 48 hours, motor responses(15). Blood pressure was measured with although the increase in the level of consciousness was a GEA brand mercury sphygmomanometer and a GEA not significant the level of cerebral edema decreased brand stethoscope that had been calibrated at the Health significantly in patients with intracerebral hemorrhage. Facility Security Center (BPFK) with the calibration Another study conducted by Rahmah also stated that certificate number YK.02.03 / L.1 / 7895/2018. there was an increase in the GCS value after 10 minutes (11) of mannitol therapy . Measurements were made by carrying out a physical examination and equipped with an observation Drug therapy cannot be viewed in separation from sheet consisting of a level of consciousness assessment the patient, the patient’s illness, or other aspects of using the GCS, measurement of vital signs using a care. The delivery of medicine inpatient health care is mercury sphygmomanometer with the GEA brand, a dynamic, inter-disciplinary and complex process that and a stethoscope with the GEA brand. Assessment of involves multiple professional competencies, theoretical neurological status and vital signs was performed after knowledge, critical thinking, and comprehensive patient 402 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
10 minutes to one hour of mannitol administration. Data were analyzed by univariate. Statistical calculations used the SPSS application for windows 15.0. so that the results can be obtained in the form of frequency and presentation (proportion).
Results Table 1. frequency distribution of Acute Stroke Respondents’ Characteristics (n=34) Characteristic f % Age 36–45 years (late adulthood) 10 29.4 46–55 years (early elderly) 17 50 56–65 years (late elderly) 7 20.6 Gender Male 27 79.4 Female 7 20.5 Educational Primary school 5 14.7 Junior high school 5 14.7 Senior high school 17 50 College 7 20.5 Profession Worked 24 70.5 Unworked 10 29.5 History of smoking Never 6 17.6 Has stopped 4 11.7 Still smoking 20 58.8 Passive smoker 4 11.7 Type of bleeding Intracerebral 29 85.2 Subarachnoid 5 14.7 Area of bleeding Basal ganglia 8 27.6 Thalamus 6 20.7 Lobar 12 41.4
Basal ganglia and thalamus 3 10.3 Past medical history
Hypertension 24 70.5 Diabetes mellitus 7 20.5 Kidney failure 3 8.82 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 403
Table.1 shows that the characteristics of acute stroke of the respondents’ marital status was married as many patients who received mannitol therapy were 46-55 as 25 respondents (73.5%), the majority of respondents years (early elderly) 50%, the majority of respondents were smokers 58.8%, the majority of type bleeding were were male 79.4%, the majority of respondents were intracerebral hemorrhage 85.2%, the majority bleeding high school graduates 50%, the majority of respondents area was lobar 41.4%), the majority of past medical worked as many as 24 respondents (70.5%), the majority history were hypertension 70.5%.
Table 2. Frequency of change in response level of consciousness of acute stroke patients (n=34)
Table.2 shows that the consciousness level of acute of acute stroke patients who received mannitol therapy stroke patients who received mannitol therapy at the first, was 58.8% with somnolent GCS 13 to 14 and 41.2% second, third, and fourth administration was that 32.4% had a soporocomatous level of consciousness GCS 8 to had a somnolent level of consciousness GCS13 to 14 12. At the ninth administration, 61.8% of acute stroke and 67.6% had a level of consciousness soporocomatus patients who received mannitol therapy had somnolent GCS 8 to 12. On the second day, namely the fifth GCS 13 to 14 and 38.2% had a soporocomatous level of administration, the consciousness level of acute stroke consciousness GCS 8 to 12). At the tenth administration, patients who received mannitol therapy was 35.3% had there were 8.9% with composmentis level of a somnolent level of consciousness GCS 13 to 14 and consciousness, 55.9% were somnolent GCS 13 to 14, 64.7% had a soporocomatus level of consciousness and 35.3%) had a soporocomatous level of consciousness GCS 8 to 12. At the sixth administration, 50% had a GCS 8 to 12. At the eleventh administration, there were somnolent level of consciousness GCS 13 to 14, and 20.6% with composmentis level of consciousness, 50% had soporocomatous consciousness GCS 8 to 12. 44.1% were samnolenic GCS 13 to 14 and 35.3% had At the seventh administration, the level consciousness a soporocomatous level of consciousness GCS 8 to 12. of acute stroke patients who received mannitol therapy In the twelfth administration, there were 23.5% with was 55.9% with somnolent GCS 13 to 14) and 44.1% a composmentis level of consciousness, 41.1% were had a soporocomatous level of consciousness GCS 8 to somnolent GCS 13 to 14 and 35.3% had moderate levels 12. At the eighth administration, the consciousness level of consciousness GCS 8 to 12.
Table 3. Frequency of change in response to a blood pressure of acute stroke patients (n=34)
Administering mannitol therapy
Blood 1 2 3 4 5 6 7 8 9 10 11 12 pressure f % f % F % f % f % f % f % f % f % f % f % f %
Normal 0 0 0 0 0 0 1 3 2 5,9 2 6 2 6 2 6 4 12 8 24 10 29 11 32
High normal 1 3 1 3 1 3 2 5,9 2 5,9 3 9 5 15 9 27 9 27 8 24 9 27 8 24
Grade 1 11 32 11 32 12 35 10 29 14 41 17 50 16 47 15 44 15 44 15 44 14 41 14 41
Grade 2 10 29 10 29 11 32 13 38 8 24 7 21 8 24 7 21 6 18 3 9 1 3 1 3
Grade 3 12 35 12 35 10 29 8 24 8 24 5 15 3 9 1 3 0 0 0 0 0 0 0 0
404 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3. shows that the blood pressure of acute stroke The arterial walls damaged by cigarette smoke will be patients who received mannitol therapy who experienced the site of accumulation of fat, platelet cells, cholesterol, hypertension up to the administration of the twelfth and thickening of the smooth muscle layer of the artery mannitol still had hypertension patients. Normal blood walls (atherothrombotic). Atherothrombotic causes the pressure can only be achieved after acute stroke patients diameter of the arterial cavity to narrow and usually received mannitol in the fourth that there was one patient causes fragility of the arterial walls, this is what causes (2.9%). On the first day of administration of mannitol, stroke(21). This study indicated that most of the 85.2% the majority of patients had grade 1 hypertension and of respondents experienced intracerebral hemorrhage. grade 2 hypertension, and on the second and third days The location of bleeding experienced by most patients of mannitol administration, the majority of patients had was the lobe (41.4%). A study conducted by Misbach grade 1 hypertension. also revealed that from 28 hospitals in Indonesia the percentage of locations for hemorrhagic strokes was Discussions 4.2% subarachnoid hemorrhage (PSA), 18.5% intra- The study indicated that the age of the occurrence cerebral hemorrhage (PIS) with a division of 8.8% lobar of hemorrhagic stroke was early elderly (46 to 55 years) hemorrhage, basal ganglia hemorrhage 7.1%, brain stem (1) 61%. The results of this study are in line with research hemorrhage 1.7%, and cerebellar bleeding 0.9% . The conducted by Sunjaya et al. found that the age range for study conducted by Musa (2017) states that the location stroke was the 45-59 age group 48.6%. Another study in of the hematoma is an independent predictor of mortality 28 hospitals in Indonesia showed that the mean age of during acute care, Almutawa, Shahda & Albalooshi also stroke was 58.8 ± 13.3 years, with an age range of 18-95 reveal that independent risk factors Significant mortality years(16). Age less than 45 years was 12.5% and more during treatment was hematoma location, hematoma (8) than 65 years was 35.8%(1). The study was found that volume, and intraventricular hemorrhage . the majority of respondents were male 79.41%. Another The study showed that the majority of patients had study conducted by Safri also found that the number of a history of hypertension with 70.58% of respondents. male respondents was more than female 73.3%(17). An The results of epidemiological studies also show that epidemiological study showed results similar to this hypertension is found in 50-70% of stroke patients. study. It was found that 75% of male patients had a Someone who has hypertension has 3-4 times the risk stroke compared with 25% of female patients(18). of having a stroke compared to people who do not have (18) This study was found that 50% of respondents had hypertension . senior high school. The level of education affects the According to Wagner et al. said that the GCS ability to understand and follow directions to be healthy, value of hemorrhagic stroke patients was more in the if a person is illiterate written information about healthy moderate and bad category when compared to the GCS behavior and healthy resources becomes worthless(19). value in non-hemorrhagic stroke patients, which was The results of this study indicated that 70.58% of (22) around 55% when admitted to hospital . In line with respondents are working. Suiraoka said that high research conducted by Baidya, Tiwari, and Usman workloads, heavy life pressures, or other things without which revealed that acute phase hemorrhagic stroke realizing it can cause long-term effects on physical and patients will experience decreased consciousness. Of mental health, one of which is stress. Stress accounts for the 50 study subjects, 25 patients (50%) had decreased 20% of the causes of stroke because stress can increase consciousness with GCS 9-12, 5 patients (10%) had a cholesterol levels in the blood which can clog arteries so GCS score of 13-15, a GCS score of 4-8 was 18 patients that you are at risk of having a stroke(20). (36%), and GCS score 3 in 2 patients (4%)(23). The study was found that the majority of patients The results of this study were supported by a were active smokers 58.82%. The study is supported by research report published by Asghari et al., which William et al. states that the number of stroke sufferers concluded that the GCS value increased slowly after who have a smoking habit is 53.8% more than the number mannitol administration. The increase occurred at 48 of stroke patients who do not have a smoking habit 23%(5). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 405
hours, although the increase in the level of consciousness therapy. There were changes in vital signs, namely an was not significant the level of cerebral edema decreased improvement in blood pressure in acute stroke patients significantly in patients with intracerebral hemorrhage(10). receiving mannitol therapy. Another study that is in line is a study conducted by Conflict of Interest: Nil Jaya, Widodo and Ganda which states that administering 20% mannitol at the start of admission to the fifth day Source of Funding: The study was initiated by the (120 hours) shows an increase in the value of GCS in author and was not externally funded. moderate head injury patients. The mean GCS value of the patient before was 11.24 and after (assessment V) Ethical Consideration: The Research Ethics was 13.72. The dynamics of GCS at the beginning and Committee from the Commission of Health Research end of the assessment showed an improvement in the Ethics Faculty of Nursing Universitas Sumatera Utara degree of consciousness began to occur on the second No. 1291/XII/SP/2017. (24) day after the administration of mannitol therapy . References The study was found that there was an increase 1. Ã GJH, Wong KSL, Chankrachang S, Chen C, in blood pressure in acute stroke patients. On the first Crimmins D, Frayne J, et al. Guidelines Management day, most of the patients had grade 3 hypertension, of cholesterol to reduce the burden of stroke in until the third day most patients still had grade 1 Asia : consensus statement. 2010;5(June):209–16. hypertension. In line with the research conducted by Al- 2. Go AS, Mozaffarian D, Roger VL, Benjamin Ghifari and Andina which also obtained the most blood EJ, Berry JD, Borden WB, et al. AHA Statistical pressure results experienced by acute stroke sufferers Update Executive Summary : Heart Disease and (25) is hypertension grade 3 with 41.3% . Likewise, the Stroke Statistics — 2013 Update A Report From the study conducted by Al-Ghifari and Andina found that American Heart Association WRITING GROUP the blood pressure of acute stroke patients was very MEMBERS. 2013;143–52. high in the first 48 hours, namely experiencing grade 3 3. Federation H. Global Atlas on cardiovascular hypertension (systolic ≥180 mmHg and diastolic ≥110 disease prevention and control. (25) mmHg) 44.1% . 4. Kesehatan K, Hipertensi RI, Senyap SP. i s n e t r Hipe. 2019; Recent research conducted by Ekayanti, Bachtiar, Mawuntu and Pertiwi revealed that changes in blood 5. Murray CJL, Vos T, Lozano R, Naghavi M, pressure in acute phase strokes can be influenced Flaxman AD, Michaud C, et al. Disability-adjusted by circadian rhythms. The circadian rhythm is an life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: A systematic analysis for endogenous physiological rhythm with a duration the Global Burden of Disease Study 2010. Lancet. of about 24 hours found in living things. Circadian 2012;380(9859):2197–223. rhythms not only regulate endogenous sleep and wake 6. Witherspoon B, Ashby NE. T h e U s e o f M a n n cycles but also influence behavior and nearly every i t o l an d Hypertonic Saline Therapies in Patients physiological function. In humans, circadian rhythms with E lev ate d I n t r ac r an i al Pre ssu re A Review are mainly controlled by the suprachiasmatic nucleus of the Evidence. Nurs Clin NA [Internet]. 2017;1– (SCN) which is located in front of the hypothalamus. 12. Available from: http://dx.doi.org/10.1016/j. The suprachiasmatic nucleus regulates molecular and cnur.2017.01.002 cellular functions which in turn affect blood pressure, 7. Anica Hadi; Mohammad Wasa. EDEMA SEREBRI pulse, respiration, body temperature, sleep time, and SEBAGAI PREDIKTOR MORTALITAS PADA another body metabolism(26). PERDARAHAN INTRASEREBRAL AKUT. Gadjah Mada; 2013. Conclusions 8. Albalooshi EAASM. Spontaneous Intracerebral There was a change in neurological status, namely Haemorrhage(SICH): Factors Associated an increase in the level of consciousness of acute with in-hospital Mortality. Bahrain Med Bull. stroke patients at 24 hours after receiving mannitol 2012;34(2):1–9. 406 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
9. Iqbal RNBKM. Causes of Mortality in Acute 18. Laily SR. Hubungan karakteristik penderita Stroke Patients in RSUP. HAM. Medan January - dan hipertensi dengan kejadian stroke iskemik. December 2011. Sumatera Utara; 2011. 2016;(February 2017):48–59. 10. Firooz Salehpour; Mohammad Asghari 19. Oh YHJ. Factors A ff ecting Health-Promoting MSHEHMKAMBYEMG. Effect of Three Behaviors among Nursing Students. Int J Environ Different Mannitol 20% Doses on Cerebral Edema Res Public Health. 2020;17. and Consciousness Levels in Traumatic Brain 20. IP. Suiraoka. Penyakit Degeneratif. Yogyakarta: Injury. 2013;10(7):1228–31. Nuha Medika; 2012. 11. Rahma YM. Efek pemberian Manitol terhadap 21. Ferdinand P, Oke A. Journal of Neurology penurunan kadar Hematokrit pada kasus & Neurophysiology Intractable Hiccups Post peningkatan tekanan Intrakranial pasca cedera Stroke : Case Report and Review of the Literature. kepala : penelitian pendahuluan = The effect of 2012;3(5). Mannitol administration on Hematocrit level 22. Wagner A, Schebesch K, Isenmann S, in cases of increased Intracranial pressure post Steinbrecher A. Interdisciplinary Decision traumatic brain injury : a preliminary study. :10. Making in Hemorrhagic Stroke Based on CT 12. Wulff K, Cummings GG, Marck P, Yurtseven O. Imaging — Differences Between Neurologists Medication administration technologies and patient and Neurosurgeons Regarding Estimation of safety: a mixed-method systematic review. 2011; Patients ’ Symptoms , Glasgow Coma Scale , 13. Dilles T, Stichele R Vander, Rompaey B Van, and National Institutes of Health Stroke Scale. Bortel L Van, Elseviers M. Nurses’ practices 2019;10(September):1–11. in pharmacotherapy and their association with 23. Omkar Prasad Baidya; Sunita Tiwari; Kauser educational level. J Adv Nurs. 2010;66(5):1072–9. Usman. Acute hemorrhagic stroke in young adults-a 14. Middleton S, Grimley R, Hons M. Triage, study in a tertiary-care hospital of North India. Int Treatment, and Transfer Evidence-Based Clinical J Biomed Adv Res IJBAR Int J Biomed Adv Res Practice Recommendations and Models of Nursing J [Internet]. 2015;6(605):427–30. Available from: Care for the First 72 Hours of Admission to Hospital www.ssjournals.com for Acute Stroke. State-of-the-Science Nurs Rev. 24. Ganda IJDWIJ. Perbandingan efek pemberian 2015;46:18–25. hipertonik salin solution 3% dan amnitol 20% 15. Bucher SLLSRDMMHL. Medical-Surgical pada pasien trauma kepala sedang. JST Kesehatan. Nursing: Assessment and Management of Clinical 2017;7(4):374–80. Problems. 9th ed. Canada: Elsevier; 2012. 25. Ghifari M Al, Andina M. ARTIKEL PENELITIAN 16. Saragih WSAKMSHAFRH. Gambaran Gambaran Tekanan Darah pada Pasien Stroke Akut Intracerebral Hemorrhage Score Pada Pasien di Rumah Sakit Umum Haji Medan Tahun 2015 Stroke Hemoragik Yang Dirawat Inap Di RSUP Blood Pressure in Acute Stroke Patient of Rumah H. Adam Malik Medan. Maj Kedokt Nusant. Sakit Umum Haji Medan , 2015. 2017;2(1). 2019;52(3):108–13. 26. Ekayanti MS, Bachtiar MF, Mawuntu AHP. 17. Safri. Pengaruh stimulasi murottal Al-Qur ’ an IRAMA SIRKADIAN PADA STROKE AKUT terhadap tingkat kesadaran kuantitatif pada pasien CIRCADIAN RHYTHM IN ACUTE STROKE. stroke hemoragik. Universitas Indonesia; 2019;2(1):9–18. DOI Number: 10.37506/ijphrd.v12i1.13881 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 407 The Impact of Work-Family Conflict and Emotional Intelligence on Nurse’s Performance at Dr. Pirngadi Hospital Medan
Romauli E. G. Siallagan1, Arlina Nurbaity Lubis2, Sri Eka Wahyuni3 1Master Program, Faculty of Nursing, Universitas Sumatera Utara, Medan, Indonesia, 2Lecturer, Faculty of Economics and Business Universitas Sumatera Utara, Medan, Indonesia, 3Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Medan, Indonesia
Abstract Objective: The study was to identify the impact of work-family conflict (WFC) and emotional intelligence (EI) on the performance of nurses at Dr. Pirngadi Hospital Medan.
Methods: Quantitative correlation descriptive with a cross-sectional design was applied in this study. The population of the research is 115 nurses. Data were analyzed by using the Spearmen correlation coefficient test.
Results: The results show that both WFC and EI impact on the performance of nurses at Dr. Pirngadi Hospital Medan. Mostly nurses (69.6 %) were highly impacted by WFC and 67.8 % of them were in the low level of EI.
Conclusion: The factor which impacts on the performance of nurses at Dr. Pirngadi Hospital Medan is dominated by emotional intelligence. Nurses should distinguish between a housewife and a nurse.
Keywords: Emotional intelligence; Performance; Work-family conflict;
Introduction However, psychologically the nurses feel guilty during doing their nursing because they feel neglected Nursing is an important profession for healthcare by their family. Many nurses could not overcome their (1) that may fulfill the patient’s needs . Female nurses are problem even though high competence. If the female (2) the majority in the hospital . Nurses are a dominant nurse could not harmonize the double function, she profession compared to the others in the healthcare case. indeed will get a problem. It potentially evokes a conflict A nurse as a healthcare worker has formal education and a between a housewife and a nurse (2). responsibility to give treatment to the patients. The nurse only has a high relationship with the patient’s family According to the study on 110 male nurses and (1). The nursing profession considered a social worker 137 female nurses indicates that female nurses more should have competence and calm in giving treatment to susceptible to work-family conflict compared to male the patients. It describes that human resources are polite nurses. Work-family conflict (WFC) is caused by a and hospitable (3). positive relationship between a housewife and a nurse. The higher the needs of both functions, the more potential of conflict (3). This study is by the research on Corresponding author: 138 married female nurses with children that 50.4 % Romauli E. G. Siallagan chronically impacted and 41.4 % impacted in the past 6 E-mail: [email protected] months (4). Another study in Madura indicates from 30 Jalan Prof. Maas No.03, Kampus USU, Medan 20155, nurses, 42 % are impacted by WFC (5). While a study in Sumatera Utara, Indonesia Italia on 500 nurses indicates that there is a correlation 408 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
between the double function (6). who is on OJT (on the job training).
Nurses are majority impacted by WFC because of The WFC questionnaire is a modified instrument heavy-duty and responsibility for the safety of the patient. from (16) study which has been well validated (higher Various characters of nurses are created by various than 0.361) to measure WFC based on the established work sections, such as shift schedule, tight discipline, model. The questionnaire has 18 positive statements rivalry among nurses (7). WFC harms the performance. consisting of a scale of 6 dimensions, time-based work However, support from teamwork may minimalize the interference with family, time-based family interference conflict and maximize the performance (8). The nurses with work, strain-based work interference with family, who impacted WFC may cause feel tired, the bad mood strain-based family interference with work, behavior- on work, etc. (9). based work interference with family, and behavior- based family interference with work. The study applied Emotional intelligence (EI) has a positive impact the Likert scale model consisting of 5 options such as: on performance (10). EI is very important to stimulate, strongly agree = 5, agree - 4, less agree = 3, disagree = 2, oppose frustration, empathize (11). Emotional control and strongly disagree = 1. must avoid conflict. Those who have a good EI can fulfill the needs of the patient including sociology, biology The modified EI questionnaire from (17) is also a (12). Both individual and company by performance well-validated scale (higher than 0.361) to measure achievement are based on EI, while the performance is WFC based on the established model. The questionnaire based on IQ(13). has 30 positive statements with a scale of 6 dimensions, consisting of self-awareness, self-regulation, self- Nurses should have morality, intellectuality, motivation, empathy, and social skills. The study applied technical ability, and interpersonal communication Likert scale with 5 options, such as: choice on a positive (9). The nurse’s performance is indicated by the statement strongly agree = 5, agree = 4, disagree = 3, nursing process and documentation. Hence, a standard disagree = 2, and strongly disagree = 1. achievement will impact the quality of nursing (14). To give quality service, the nurse should have The modified performance questionnaire from communication ability, investigate health conditions Mangkunegara was also well-validated (higher than with an interview, check physic, diagnosis defining, and 0.419) to measure WFC based on the established model. collaboration with teamwork (15). The questionnaire has 22 positive statements with a scale of 5 dimensions consisting of assessment, nursing Methods diagnosis, nursing planning, nursing implementation, The study was conducted using correlation and nursing evaluation. The study applied the Likert descriptive study with a cross-sectional approach. The scale with 4 options in positive statements, namely: do/ (18) study was conducted at Dr. Pirngadi Hospital Medan. yes value of 1 and not done/no value of 0 . The subject was 115 selected by total sampling. Chi-square was applied to examine the relationship Inclusion criteria, namely: the nurse is female; married between EI and the nurse’s performance at RSUD has children; minimum education level is Diploma III Dr. PirngadiKota Medan. Multivariate analysis with in nursing; length of work>2 years; nurses who have multiple logistic regression was used to measure the children under 21 years of age; and BOR for inpatients> highest influence on nurse’s performance. 40%. Exclusion criteria, namely: study permit; and nurse Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 409
Results Table.1 characteristic of nurses at Dr. Pirngadi Hospital Medan (n=115)
No Variable Frequency %
Age
1 <21 years 3 2.6
2 21-30 years 39 33.9
3 31-40 years 45 39.1
4 41-50 years 27 23.5
5 >50 years 1 0.9
Total 115 100
Education
1 Diploma III 73 63.5
2 Ners 42 36.5
Total 115 100
Length of working
1 1-5 years 54 46.9
2 6-10 years 22 19.1
3 >10 years 39 33.9
Total 115 100
Work-family conflict (WFC)
1 Low 80 6.,6
2 High 35 30.4
Total 115 100
Emotional Intelligence (EI)
1 High 37 32.2
2 Low 78 67.8
Total 115 100
Performance
1 Good 36 31.3
2 Bad 79 68.7
Total 115 100
Table 1. shows that characteristics of nurses at Dr. Pirngadi Hospital Medan as follows: majority nurses (39.1%) aged 31 to 40 years old and minimum nurses (0.9 %) aged >50 years old. Mostly (63.5%) nurses are based on Diploma (D3) as educational background. Based on the length of working, mostly nurses (46.9%) work 1 to 5 years, 410 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 and others (19.1%) work 6 to 10 years. Mostly nurses (69.6 %) at Dr. Pirngadi Hospital Medan are highly impacted category by WFC and 67.8 % of nurses are in the low level of Emotional Intelligence, while 68.7% of nurses are in bad performances.
Table. 2 relationship between work-family conflict and nurse’s performance Performance Total ᵡ2 p-value No Work-Family Conflict (WFC) Good Poor
f % f % F %
1 High 4 25.5 76 55 80 100 0.000 84,575 2 Low 32 11 3 24 35 100
Emotional Intelligence (EI)
1 High 28 11.6 9 25.4 37 100 0.000 49,943 2 Low 8 24.4 70 53.6 78 100
Table 2. shows that bivariate analysis is to is a relationship between work-family conflict and determine the relationship between work-family conflict performance of the nurses at Dr. Pirngadi Hospital together with emotional intelligence and performance Medan. Of 37 nurses with a high level of emotional of nurses at Dr. Pirngadi Hospital Medan by using a intelligence, there are 11.6 % in good performances chi-square test with p-value = 0,05. Table 3 shows of and 25.4 % are bad performances. Of 78 nurses with 80 nurses impacted by WFC at a high level, there are a low level of emotional intelligence, there are 24.4 % 25.5 % in good performances and 55.0 % are in bad in good performances and 53.6 % in bad performances. performances. Of 35 nurses impacted by WFC at a Based on chi-square test, so: p=0,000<α=0,05. Ho is low level, there are 11.0 % in good performances and rejected means there is a relationship between emotional 24.0 % in bad performances. Based on the chi-square intelligence and performances of the nurses at Dr. test, so: p=0,000<α=0,05, Ho has rejected means there Pirngadi Hospital Medan.
Table. 3 Impact of work-family conflict and emotional intelligence on the performance of nurses at Dr. Pirngadi Hospital Medan.
95% C. I for Exp(B) Independent Variable B-value p-value Exp (B)
Lower Upper
Work-family conflict (WFC) -5.502 0.000 0.004 0.000 0.038
Emotional intelligence (EI) 3.540 0.002 34.480 3.797 313.103
Constant -2.944 0.46 18.984 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 411
Table 3 shows that independent variables of work- remuneration, support, ability, perception on the job, family conflict with p-value 0.000 (p < 0.05) and and work satisfaction(19). Referring to the study of (20) emotional intelligence with p-value 0.000 (p < 0.05) have that work satisfaction impacts on the performance of an impact on the dependent variable of performance of nurses. It indicates that besides emotional intelligence, nurses at Dr. Pirngadi Hospital Medan. Multiple logistic other factors also influence the performance of nurses. regression was applied to examine the relationship with a significant level < 0.05. It indicated that emotional Conclusions intelligence has a dominant influence 34.480 (95 % CI This study concludes that work-family conflict = 3.797-313.103. and emotional intelligence significantly impact on the performance of nurses at Dr. Pirngadi Hospital Medan Discussions with OR = -5,502, and coefficient of 3.540 on the Among the highly impacted WFC category, there emotional intelligence variable. It means the factor which are 55 % in poor performances. While in those who impacts on the performance of nurses at Dr. Pirngadi low category, there are 11 % good performances. Hospital Medan is dominated by emotional intelligence. Based on multiple logistic regression tests that there is Nurses should distinguish between a housewife and a a significant relationship between work-family conflict nurse. To do the best on duty, the nurses need support and performance of nurses at Dr. Pirngadi Hospital from the family and colleagues. Setting working hours Medan with value p=0,000< α=0,05. Nurses in the high must be flexible to accommodate the double function of category of WFC, their performances will decrease, a female nurse. The management of the hospital should conversely those who have the low category of WFC, hold training in ESQ to improve the caring service of the performances will be better. The nurses who have a the nurse. Other activities are crucial to intensify the high category of WFC is caused by the double functions, performance because a study at Dr. Pirngadi Hosptal as a housewife and a nurse. A housewife also has a in 2008 indicated 59.6 % of nurses in moderate stress, responsibility to take care of the children and sometimes 9.9 % in high-level stress, and 4.6 % in very high-level has to skip the schedule at work. As a profession, a nurse stress. It can be concluded that the nurses at Dr. Pirngadi has to obey the schedule at work and other regulations Hosptal are at moderate stress levels. and sometimes has no time for the family. On the side, Conflict of Interest: Nil even though the nurses have a high category of WFC, but they can do the best nursing for the patients because Source of Funding: The study was initiated by the they think that the quality service is very important. author and was not externally funded.
11.6 % of nurses having high emotional intelligence Ethical Consideration: The Research Ethics are good performances, and 53.6 % of low-level Committee from the Commission of Health Research emotional intelligence are poor performances. Based on Ethics Faculty of Nursing Universitas Sumatera Utara multiple logistic regression tests, there is a significant No. 1872/VI/SP/2019 relationship between emotional intelligence and the performance of nurses at Dr. Pirngadi Hospital Medan References with a value p=0,000< α=0,05. It can be inferred that 1. Haryanti H, Aini F, Purwaningsih P. Hubungan the nurses having a high emotional intelligence will Antara Beban Kerja Dengan Stres Kerja Perawat Di serve better, conversely, for those having low emotional Instalasi Gawat Darurat Rsud Kabupaten Semarang. intelligence will be worse service. The nurses who can J Manaj Keperawatan. 2013;1(1):111590. control their emotions well will ease to develop their 2. Desi Wulandari RD. Relationship Between the Role initiative. Those have a good relationship with others Conflict With Multiple. Psycho Idea. 2014;33–41. will also impact on performance. Based on results, there 3. Susanti S. Peran Pekerjaan, Peran Keluarga Dan are three nurses with high emotional intelligence but they Konflik Pekerjaan Pada Perawat Wanita. Pers have poor performances. According Darmadi said that Psikol Indones. 2013;2(2):183–90. many factors impact individual performance including 412 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
4. Takeuchi T, Yamazaki Y. Relationship between 12. Anand R, Perrelli R, Zhang B, Papi L, Koeva work-family conflict and a sense of coherence Brooks P, Allard C, et al. WP/16/24 South Africa’s among Japanese registered nurses. Japan J Nurs Exports Performance: Any Role for Structural Sci. 2010;7(2):158–68. Factors? IMF Working Paper African Department 5. Khoiroh M. Hubungan Konflik Peran Ganda Kerja- and Strategy, Policy, and Review Department Keluarga dengan Kesejahteraan Psikologis Perawat South Africa’s Exports Performance: Any Role for Perempuan di Puskesmas Guluk-Guluk Sumenep Structural Factors*. 2016; Madura. Universitas Islam Negeri Maulana Malik 13. MacCann C, Jiang Y, Brown LER, Double KS, Ibrahim Malang. 2015; Bucich M, Minbashian A. Emotional Intelligence 6. Ghislieri C, Gatti P, Molino M, Cortese CG. Predicts Academic Performance: A Meta-Analysis. Work–family conflict and enrichment in nurses: Psychol Bull. 2019;146(2):150–86. between job demands, perceived organisational 14. Barker LM, Nussbaum MA. Fatigue, performance support and work–family backlash. J Nurs Manag. and the work environment: A survey of registered 2017;25(1):65–75. nurses. J Adv Nurs. 2011;67(6):1370–82. 7. Widyasari Y. Persepsi Mahasiswa Akuntansi 15. Simamora RH, Bukit E, Purba JM, Siahaan J. Mengenai Faktor-Faktor Yang Membedakan Penguatan Kinerja Perawat Dalam Pemberian Pemilihan Karir (Studi pada Universitas Asuhan Keperawatan Melalui Pelatihan Ronde Diponegoro dan UNIKA Soegijapranata. 2010; Keperawatan Di Rumah Sakit Royal Prima Medan. 8. Wang ML, Tsai LJ. Work-family conflict and job J Pengabdi Kpd Masy. 2017;23(2):300. performance in nurses: The moderating effects of 16. Carlson DS, Kacmar KM, Williams LJ. Construction social support. J Nurs Res. 2014;22(3):200–7. and Initial Validation of a Multidimensional 9. Wibowo. Manajemen kinerja. V. Jakarta: Rajawali Measure of Work-Family Conflict. J Vocat Behav. Pers; 2017. 2000;56(2):249–76. 10. Uha IN. Budaya Organisasi Kepemimpinan dan 17. Daniel Goleman. Emotional Intelligence. Jakarta: Kinerja. Jakarta: Kencana; 2013. Gramedia Pustaka Utama; 2015. 11. Rantika R, Sunjoyo. Pengaruh Konflik Kerja- 18. Anwar Prabu Mangkunegara. Manajemen Sumber Keluarga Terhadap Komitmen Oragnisasi yang Daya Manusia Perusahaan. Bandung: PT REMAJA Dimediasi oleh Kepuasan Kerja Pada Profesi ROSDAKARYA BANDUNG; 2007. Perawat di Rumah Sakit Umum Daerah (RSUD) 19. Hamid Darmadi. Metode penelitian pendidikan DR. Moewardi Surakarta. J Manaj Teor dan dan sosial : (teori konsep dasar dan implementasi). Terap [Internet]. 2011;4(2):28–43. Available Bandung: Alfabeta; 2014. from: https://e-journal.unair.ac.id/JMTT/article/ 20. Mulyono. Pengaruh Kinerja Perawat di Rumah Sakit viewFile/2418/1773 TIngkat III Ambon. Junal AKK. 2013;2(1):18–26. DOI Number: 10.37506/ijphrd.v12i1.13882 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 413 Impact of Unrealistic Optimism on the Risk of Contamination During The Home Confinement of COVID-19 in Algeria
Saad Eddine Boutebal 1, Samia Yahi2, Azzeddine Madani 1 1Faculty of social and human sciences, Khemis-Miliana University, 44225, Algeria; 2Faculty of social sciences, Algiers University, 16000, Algeria; 1Faculty of social and human sciences, Khemis-Miliana University, 44225, Algeria
Abstract The study was conducted to investigate the impact of unrealistic optimism on the risk of contamination at home confinement and its association with certain social variables.
Methods: An online questionnaire was sent to a sample of respondents. Participants (n = 558, 60.6% women and 39.4 men) subjectively assessed the risk of their coronavirus infection in the period May 1 to 15, 2020.
Results: 69.2% of the participants confirmed their respect always, and 38.7% confirmed that they rarely wear the mask, while 24% of the sample confirmed that they only sometimes wear the mask when they leave the house, including 50.5% of the sample confirmed that people infected with the coronavirus suffer from social stigmatization. 54.8% of the respondents had an average level of unrealistic optimism, where the mean of participants was (36, 17 ± 5, 97). The study found an association between the levels of unrealistic optimism and respect the home confinement (P = 0.001); whereas, the results showed that there is no association between the levels of unrealistic optimism and wearing the mask (P = 0.183). The results did not show any statistically significant differences in unrealistic optimism between groups of gender among Algerian citizens during the home confinement (P = 0, 0835).
Conclusions: Unrealistic optimism is linked to avoiding risky behaviors that threaten human life as it is the case with the COVID-19. It is important to reduce the levels of unrealistic optimism of individuals with beliefs and objective information to avoid dangerous behavior during this pandemic.
Keywords: unrealistic optimism, home confinement, Covid-19 pandemic, social variables, Algerian citizens.
Introduction and also the United States have recorded many cases and deaths. So, this is a pandemic with high contamination COVID-19 is a severe infectious disease caused that has affected other countries such as Algeria. The by the novel coronavirus SARS-COV-2, and it has no number of cases has rapidly increased in all continents treatment or specific vaccine at the moment; however, of the world, and it has caused a pandemic. There is no it is highly transmittable and spreads rapidly in various treatment and the vaccine will not be available at the countries, especially in Europe (Italy, Spain, and France), moment, and the most affected by the virus are Spain, Italy, and the United States. In Algeria, the virus has spread, but the situation is not as alarming. Corresponding author: Prof. Saad Eddine Boutebal The first case of Covid-19 was identified in Algiers, Lecturer, Department of social sciences and he was an Italian national from Lombardy and it is Faculty of social and human sciences, Khemis Miliana one of the most affected areas in Italy, who arrived in University, Algeria. Algiers on February 17. This first case was then placed Email: [email protected] in isolation 1. Confirmed cases jump in Algeria and the Telephone Number: +213 771846244 Ministry of Health and Population and Hospital Reform 414 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
notified on Monday, May 11, 2020 about 168 new related to cognitive factors such as lack of information confirmed cases of COVID-19 coronavirus, to reach a and the poor critical insight into one’s cognitive skills. total of 5891 out of 48 cities, while 04 cities have not The second mechanism has a motivational nature which reported any cases in the past 24 hours. The Algerian is closely tied to defending one’s self-esteem and to regions: Oran, Adrar, Ain defla, Tlemcen recorded defensive negation 7. For Weinstein and Klein unrealistic more than 56% of active persons aged 25 to 60 years, optimism would be a protective strategy, allowing us to and 05 new deaths, to reach a total of 507 deaths and believe that all is well. It is accompanied by attrition, 66.3% of the deceased persons are aged 65 years, over external causal gains (“I was born under a lucky star”), 163 are cured, 18 patients are hospitalized in intensive and the lack of effort to lead a healthy life. It leads to care, 9557 are under the new treatment protocol based underestimating the risk of many health problems 8. on chloroquine, and 2841 patients recovered. The The study of Benjamin J Kuper-Smith and Lisa Ministry of Health calls for the need to remain vigilant Doppelhofer in which they tested individuals’ beliefs and to respect preventive measures during confinement. about infection probabilities and abilities to practice Strict compliance with the rules of hygiene and social social distancing in UK, USA and Germany, in this rapidly distancing remains the main measure of protection evolving situation, they report here initial analyses. They against the spread of the coronavirus 2. found that individuals show an optimism bias as they The Algerian authorities have prepared a notice estimated the probability of getting infected with the relating to the establishment of the Covid-19 infection virus, and infecting others is lower for themselves than surveillance and alert system. On March 24, 2020, for someone similar to them 9. While optimism bias may schools are closed, recreational areas, travel restrictions, be useful for avoiding negative emotions, it can lead social distance are compulsory. From March 15 to 21 people to underestimate their likelihood of contracting a authorities published the Decree N20-69 relating to disease and ignoring public health warnings 10. the strengthening of preventive measures (closure of A study conducted in Hubei revealed that nearly all mosques), and on March 14, 2020, decree No. 20-70 the participants 98.0% wore masks when going out. In establishing additional preventive measures against the recent days, most of them, women in particular, with spread of the coronavirus (home confinement, sanctions) knowledge about COVID-19 hold optimistic attitudes 3. and maintain appropriate practices 11. The objectives Despite confinement measures and restrictions of this study were to explore the level of unrealistic by the government, citizens begin to disregard home optimism among Algerian citizens during the home containment prevention instructions, and continue to go confinement of the coronavirus. Accordingly, this study out, because they usually assess risks through optimistic is about determining the association of social variables naive or unrealistic optimism and as Weinstein claimed, with unrealistic optimism among Algerian citizens people tend to think they are invulnerable. They expect outside the home confinement of the coronavirus, and at others to be the victims of misfortune, not themselves. the same time discovering the differences in the level of “life optimism implies an error in judgment “ which unrealistic optimism between male and female citizens. Weinstein called unrealistic optimism or optimistic bias To this end, the present study seeks to answer the 4. Taylor and Brown defined unrealistic optimism as part question of association between the unrealistic level of of a pattern of the so-called positive illusions that help us optimism and social variables among Algerian citizens cope with potentially threatening experiences. Although, outside the home confinement of the coronavirus. people are usually unrealistically optimistic, and this is not always the case. The unrealistic optimism is defined Materials and Methods as the tendency for people to believe that they are “less Study Design likely to experience negative events and more likely to experience positive events than are other people” 5,6. Regarding the design of this research, we have The optimistic bias has been defined as the result of the decided to assess the factors causing risky behavior joint efforts of two mechanisms. The first of these is related to home confinement in Algeria such as Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 415 optimism, especially with the spread of the coronavirus unrealistic optimism on the risk of contamination of in all regions of the country, taking into consideration Algerian people between 1-15 may 2020; the sample the short duration of this study and the speed of data size was determined in the time-sensibility of the collection using an online questionnaire. So, the first pandemic COVID-19 in Algeria, and for this purpose, phase of our study took place from April 24 to 30, we adopted snowball sampling. This procedure, on the 2020. After the lift of confinement, when the increase in one hand, ensured the anonymity of the participants and infected cases and the disrespect of prevention conditions their free flotation to participate in the study and, on the are noticed, the Algerian authorities announced the other hand, it allowed us to obtain immediate answers return to confinement. This situation led us to decide according to the objectives of the study. So, with 558 to immediately carry out the second phase of the study. responders accepted to respond to the questionnaire, it During the following fortnight (from May 1 to 15, 2020), was distributed to students online. So, the questionnaire and several new cases were reported in different places comprised 20 questions including demographic data. in Algeria. The sample consisted of 338 females and 220 males.
Procedure Unrealistic optimism was measured using a 14-items questionnaire designed on the standards of the Likert In this study, we investigated the impact of scale and includes five response options.
Number of Items The min score The max score 14 items 14 70
Low level Average level High level Levels of unrealistic optimism (mean 14 – 35) (mean 35 – 49) (mean 49 – 70)
To ensure that the unrealistic optimism questionnaire (SPSS Inc, Chicago, Il, USA), and descriptive statistical would likely produce the same results for all recurring methods (number, percentage, mean and standard measures, whether within the same or a similar deviation). Chi- square test was used to calculate the population, reliability tests are essential. Therefore, we association between the respect of home confinement calculated the Cronbach’s alpha correlation coefficient and the levels of unrealistic optimism among Algerian (0.705). The internal validity of the questionnaire is citizens during the home confinement of coronavirus, confirmed, and all the correlation coefficients between and t-test was used to assess the difference between the items and the total score of the questionnaire are two groups of gender in the unrealistic optimism positive and statistically significant (0.05 and 0.01). among Algerian citizens during home confinement of coronavirus. Also, we used multiple linear regression Statistical analysis analysis to measure the effect of age in unrealistic The data were evaluated using the Statistical optimism, so the data obtained were evaluated within Package for the Social Sciences for Windows SPSS22.0, 95% confidence interval and 5% significance level. 416 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Results Descriptive statistics of study variables
Table 1. Descriptive statistics of socio-demographic variables among Algerian citizens during the home confinement of coronavirus (n = 558).
Variables n %
Gender
Male 220 39,4
Female 338 60,6
Age
(15 – 30) 282 50,5
(30 – 45) 198 35,5
(45 – 60) 76 13,6
(60- 75) 02 2,4
Respect home confinement
Always 386 69,2
Sometimes 136 24,4
Rarely 36 6,5
Wear the mask when you leave the house
Always 204 36,6
Sometimes 138 24,7
Rarely 216 38,7
social stigmatization
Yes 282 50,5
No 276 49,5
According to the results presented in Table 1, the found that 69.2% of the participants confirmed their study sample consisted of 60.6% females and 39.4% respect always, whereas 24.4% confirmed perfect, while males. In addition, 50.5% of the respondents are aged only 6.5% of the respondents insisted that confinement between 15 to 30 years, and 35.5% are aged 30 to 45 at home was rarely respected. Regarding the wearing of years, while 13.6% are between 45 and 60 years, and a mask when leaving the house, the results in Table 1 2, 4% of participants are between 60 and 75 years old. indicate that 38.7% confirmed that they rarely wear the Concerning the respect of confinement at home, it is mask, and in the same direction, 36% of the sample said Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 417 they still wear the mask, while 24% of the sample confirmed that they sometimes wear the mask when they leave the house. From the results in Table 1, it is concluded that 50.5% of the sample confirmed that people infected with the coronavirus suffer from social stigmatization, while 49.5% said that social stigmatization does not exist in the social life of people infected with coronavirus.
Unrealistic optimism among Algerian citizens during the home confinement
Table 2. Levels of unrealistic optimism among Algerian citizens during the home confinement of coronavirus (n = 558).
N= 558 Items Mean Relative unrealistic optimism Rating n % weight
Strongly Agree 74 13,3
Agreed 244 43,7
I think that I could be infected with the Neutral 164 29,4 2,49 49,80 09 coronavirus. Disagree 44 7,9
Strongly Disagree 32 5,7
Strongly Disagree 40 7,2
Disagree 102 18,3 My immunity protects me from infection with the coronavirus. Neutral 210 37,6 3,11 62,20 03
Agreed 168 30,1
Strongly Agree 38 6,8
Strongly Disagree 46 8,2
Disagree 142 25,4
I will not have health complications Neutral 246 44,1 2,84 56,80 due to coronavirus. 05
Agreed 106 19,0
Strongly Agree 18 3,2 418 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Cont... Table 2. Levels of unrealistic optimism among Algerian citizens during the home confinement of coronavirus (n = 558).
Strongly Disagree 144 25,8
Disagree 244 43,7
People of my age will not be infected Neutral 122 21,9 2,16 43,20 with the coronavirus. 10
Agreed 32 5,7
Strongly Agree 16 2,9
Strongly Agree 12 2,2
Agreed 40 7,2
I think that the coronavirus is not a Neutral 86 15,4 3,98 79,60 threat to my life. 01
Disagree 230 41,2
Strongly Disagree 190 34,1
Strongly Agree 246 44,1
Agreed 264 47,3
Preventive measures reduce infection Neutral 36 6,5 1,67 33,40 of the coronavirus. 13
Disagree 12 2,2
Strongly Disagree // //
Strongly Agree 244 43,7
Agreed 270 48,4 Social distancing protects me from possible infection with the Neutral 38 6,8 1,66 33,20 coronavirus. 14 Disagree 4 ,7
Strongly Disagree 2 ,4 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 419
Cont... Table 2. Levels of unrealistic optimism among Algerian citizens during the home confinement of coronavirus (n = 558).
Strongly Disagree 76 13,6
Disagree 158 28,3
I think that I am completely immune to Neutral 148 26,5 2,80 56,00 infection with the coronavirus. 06
Agreed 152 27,2
Strongly Agree 24 4,3
Strongly Disagree 170 30,5
Disagree 294 52,7
Coronavirus only affects people with Neutral 52 9,3 1,95 39,00 chronic diseases. 11
Agreed 38 6,8
Strongly Agree 4 ,7
Strongly Disagree 44 7,9
Disagree 176 31,5
I think the coronavirus will disappear Neutral 206 36,9 2,81 56,20 soon. 07
Agreed 104 18,6
Strongly Agree 28 5,0
Strongly Agree 236 42,3
Agreed 258 46,2 Coronavirus can affect everyone without exception. Neutral 38 6,8 1,74 34,80 12
Disagree 24 4,3
Strongly Disagree 2 ,4 420 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Cont... Table 2. Levels of unrealistic optimism among Algerian citizens during the home confinement of coronavirus (n = 558).
Strongly Disagree 24 4,3
Disagree 102 18,3
More than others, I can avoid Neutral 180 32,3 3,25 65,00 infection with the coronavirus. 02
Agreed 212 38,0
Strongly Agree 40 7,2
Strongly Disagree 38 6,8
Disagree 166 29,7 I have enough skills to avoid being infected with the coronavirus on the Neutral 170 30,5 2,94 58,80 street. 04 Agreed 162 29,0
Strongly Agree 22 3,9
Strongly Disagree 52 9,3
Disagree 170 30,5
I will not get hurt Neutral 210 37,6 2,78 55,60 08
Agreed 102 18,3
Strongly Agree 24 4,3
High level 08 (1,4) (mean 49 – 70) Levels of Average level 306 (54,8) unrealistic optimism (mean 35 – 49) low level 244 (43,7) (mean 14 – 35)
Tables 1 indicates that levels of unrealistic optimism Among the indicators of the spread of unrealistic among Algerian citizens during the home confinement optimism for the study sample, it is found that their of coronavirus are divided into three parts. First, 54.8% conviction with the coronavirus does not pose a threat to of the respondents had an average level of unrealistic their lives, and that they have more capacity than others optimism, where the mean of participants was (36,17 ± to avoid infection, especially, since their immunity 5,97). Second, 43.7% of them had a low level. Third, is strong according to their thinking, in addition to only 1.4% of the sample had a high level of unrealistic their enormous confidence in their capacity to avoid optimism. infection by the coronavirus during social interaction. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 421
Accordingly, they do not believe that they are exposed objective risk to human health and life can be a breaking to health complications due to the coronavirus, and this factor to home confinement, and may further increase poor estimation of the objective risk is reflected in their the spread of the coronavirus epidemic. conviction that they are completely away from infection Association between respect home confinement and with the coronavirus; they are convinced that this virus wear the mask with the levels of unrealistic optimism will disappear very soon because the idea of infection does not exist in their imagination. So, the reduction of
Table 3. Association between respecting home confinement and wearing the mask with the levels of unrealistic optimism among Algerian citizens during the home confinement of coronavirus (n = 558).
Variables Respect home confinement Wear the mask when you leave the house
level of unrealistic All Always Sometimes Rarely Always Sometimes Rarely P-Value P-Value optimism (n=558) (n = 386) (n = 136) (n = 36) (n = 204) (n = 138) (n = 216)
High level 08 (1,4) 06 (1,1) 00 2 (0,4) 02 (0,4) 04 (0,4) 02 (0,4) 122 110 Average level 306 (54,8) 226 (40,5) 58 (10,4) 22 (3,9) 74 (13,3) (21,9) (19,7) 0,001 0,183 104 Low level 244 (43,7) 154 (27,6) 78 (14,0) 12 (2,2) 80 (14,3) 60 (10,8) (18,6)
Table 3 also shows that the unrealistic optimism staying at home and avoiding the social interactions that level was the average level 54.8%, followed by low cause the spread of the infection. level 43.7%, and a high level 1.4%. This means that By contrast, the results of table 3 show that there the respondents had confirmed the existence of the is no association between the levels of unrealistic subjective perception and underestimated the risk linked optimism and wearing the mask (P = 0.183). According to the coronavirus. This is why we find individuals to the results, we observed a dispersion in the responses leaving their homes during the times of confinement of the respondents who have low and average levels of without any fear of losing their lives on one side, and unrealistic optimism concerning the wearing of masks infecting their families on the other side. outside the house. Hence, 38.3% of respondents said The results in the table show that there is an that they rarely wear a mask when they leave the house, association between the levels of unrealistic optimism 36.2% among them said sometimes, and 24.1% of nd respecting the home confinement (P = 0.001). It is respondents said all the time, but this is due to the rarity also noticed that 40.5% of respondents with an average of masks in pharmacies, and even the negligence of the level of unrealistic optimism confirm their total respect effectiveness of masks to fight against the corona virus. for confinement, and even 27% of them had a low level In effect, this behavior is predominant in our social life, of unrealistic optimism. They focus on the importance of which requires measures to impose the wearing of masks staying at home during the pandemic (COVID-19), which to all who go outside to public places. means that the low level of unrealistic optimism pushes Association between the level of unrealistic people to objectively assess the risks of coronavirus and optimism and age the need to take preventive instructions into account, which will include the belief in the effectiveness of 422 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 4. Association between the level of unrealistic optimism and age among Algerian citizens during the home confinement of coronavirus (n = 558).
Variable R2 AR2 Beta t P-Value
age ,006 ,004 -,119 -2,820 0,005
According to the results shown in Table 4, there is the risk according to life experiences, so they prefer to significantly a negative association (B = -, 119, P = 0.005) avoid the danger of death due to coronavirus. Contrary to with unrealistic optimism and the age among Algerian young people who often love adventure and risk-taking, citizens during the home confinement of coronavirus. and this is what we see in reality as many young people This means that the elderly have low unrealistic neither adhere to home confinement nor feel anxiety or optimism scores because of their objective perception of fear for their lives, and this is due to the high level of unrealistic optimism they have.
The differences in the unrealistic optimism between the groups of gender
Table 5. The differences in the unrealistic optimism between the groups of gender among Algerian citizens during the home confinement of coronavirus (n = 558).
Male (220) Female (338)
Variables T P-Value Standard Standard Mean Mean deviation deviation
Unrealistic optimism 36,2364 5,74961 36,1302 6,11809 ,208 ,835
Table 5 indicates that there is no significant awareness of the respondents who are informed that difference about the unrealistic optimism between the containment is important to fight the virus. In the United groups of gender among Algerian citizens during the States, a study indicates that home confinement ensures a home confinement of coronavirus (P = 0,0835). This 30.2% reduction in cases per week, a 48.6% reduction in means that the gender variable is not linked to optimism, cases after three weeks, and a 59.8% reduction in weekly since it represents a psychological characteristic linked deaths after three weeks 12. In addition, the closure to behavior in general, including behaviors linked to the and containment in Wuhan slowed the spread of the home confinement. epidemic to other cities by about 2.9 days 13. Knowing that the epidemiological impact of displacement Discussion restrictions has not yet been explicitly evaluated 14 if This study is an immediate investigation of people respect social distancing and a safety distance. unrealistic optimism among Algerian citizens during However, containment should remain the priority for the home confinement of coronavirus. The results show the moment and especially that it is not surprising that that 69.2% of participants confirmed their strict respect one day broader containment measures are necessary 15,16 for home confinement. This is linked to the level of to prevent the pandemic . The respondents who fail to respect confinement must certainly have enormous Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 423
difficulties in accepting confinement as it was the case of unrealistic optimism and wearing the mask (P = 0.183). during the SARS epidemic in Toronto (Canada) where This is due to the information that has circulated on the a significant proportion of people in their forties were containment strategy undertaken by many countries in psychological distress 17. Or, since the severity of the which was efficient and which enabled Wuhan to return epidemic was not widely disseminated or recognized at to a normal life. Knowing that the Chinese government the outset, which delayed the containment measures and has worked to improve public awareness of prevention the support of the population 18 for protecting themselves and intervention strategies by providing daily updates from COVID- 19. of information, and psychologists and psychiatrists have used the internet and social media to help people This study indicates that 38.7% of responds 24. However, the absence of association between the confirmed that they rarely wear the mask, while 24% levels of unrealistic optimism and the wearing of masks of them confirmed that they only sometimes wear is mainly linked to the contradictions on the usefulness masks when they leave the house. This shows that the of wearing masks, launched at the beginning of the information disseminated on the usefulness of wearing epidemic by the media, before coming back in to say the mask was not clear at the beginning of the epidemic, that it is important to wear the mask, despite being although modeling studies estimate the number of unavailable in pharmacies. reproductions of the disease at 6.47, which represents a very high value to that estimated by the World Health It is found in this study that there is significantly Organization (WHO) from 1.4 to 2.5 19. The shortage of a negative association (B = -0,119, P = 0.005) with the masks in Algeria caused a problem at the start of the unrealistic optimism and age among Algerian citizens pandemic, even though the masks proved to be useful during the home confinement of coronavirus. So, the in preventing diseases in healthy people and preventing results of our study demonstrate that the age variable is asymptomatic transmission. Thus, the use of face masks negatively associated with unrealistic optimism, in effect, by the entire population is of great value in reducing the the elderly have more social experiences, awareness and spread of the disease, even if masks are made at home objective perceptions of the risk, in particular, linked to and of a relatively low quality, which can help countries the coronavirus, which means they are able to estimate plan their strategy of lift the confinement20,21 . risks objectively and prudently, unlike young people who are generally distinguished by the love of adventure, The study reveals that 50.5% of the sample confirmed impulsiveness risk, and this appears in their treatment that people infected with the coronavirus suffer from of the instructions for confinement at home because of social stigmatization. This is linked to the fear of people coronavirus. who do not have enough information about the virus. In addition, stigma is associated with many health This study indicates that there is no significant problems, which requires adequate awareness capable difference concerning the unrealistic optimism between of minimizing and facilitating acceptance in the general the groups of gender among Algerian citizens during population 22, 23. the home confinement of coronavirus (P = 0. 0835). In comparison, 5 confirm that unrealistic optimism was As a result of the study, it is found that 54.8% of mainly observed in men in the three measures, but also the respondents had an average level of unrealistic women in two measures; therefore, the phenomenon of optimism, where the mean of participants was (36,17 unrealistic optimism was observed especially among ± 5,97). Since they have the necessary information on men. This study has several limits related to the time- social networking, but it seems that the course of the sensibility of the pandemic (COVID-19). For this disease has also influenced this category. The rest of the purpose, a snowball sampling is adopted, knowing respondents needed more awareness. that it is not based on random selection, and the study The results show that there is an association between population did not reflect the reality of the general the levels of unrealistic optimism and respecting the population. home confinement (P = 0.001). By contrast, the results show also that there is no association between the levels 424 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
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Saifon Bunyachatakul1, Phuanjai Rattakorn2, Peeraya Munkhetvit2, Sompong Sriburee3 1PhD candidate, Doctoral Degree Program in Biomedical Science, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand, 2Assistant Professor, Department of Occupational Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand, 3Lecturer, Department of Radiologic Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
Abstract Background: The cognitive deterioration occurring in normal aging results in the alteration of brain white matter structure and neuronal connectivity. Thus, cognitive training is beneficial in enhancing the cognitive functions in elders with cognitive impairment. The diffusion tensor imaging method explores the nature of the white matter changes occurring during cognitive intervention. This study aimed to examine white matter integrity parameters in brain-related memory between elderly with cognitive impairment who received memory training and a non-trained group.
Methods: Twenty participants were recruited for this study, and were assigned into experimental and control groups. The experimental group received a 36-session multimodal episodic memory training (MEMT) over a 12-week period. The magnetic resonance imaging scanned the corpus callosum, fornix, cingulum, and uncinate fasciculus, and then were analyzed using diffusion tensor imaging methods during, before, and after training.
Results: After MEMT training, the white matter integrity indices all targeted brain area demonstrated no significant differences (p>0.05). However, the FA values of uncinated fasciculus areas showed the tendency to increase after training.
Conclusion: This finding could indicate the resilient anatomical possibilities of white matter structural changes after training. Moreover, the DTI technique has possible benefits regarding predicting the individualized white matter alternation underlying cognitive changes in the elderly.
Keywords: community-dwelling elderly, diffusion tensor imaging, elderly with cognitive impairment, episodic memory training
Introduction occurs in normal aging processes results in common problems across a variety of cognitive domains such Cognitive functioning gradually declines over time as slow speed of information processing that affects with increasing age. The cognitive deterioration that attention and memory.1 Mild cognitive impairment (MCI) is the mid-stage between the expected cognitive Corresponding Author: decline of normal aging and dementia, and 20% – 50% of Dr. Sompong Sriburee, MCI will develop dementia over a period of 2–3 years.2 Department of Radiologic Technology, Faculty of Moreover, the elderly with MCI often demonstrate Associated Medical Sciences, Chiang Mai University, deficits in certain cognitive domains, particularly in 110 Intawarorot Rd., Sripoom, Muang, Chiang Mai episodic memory, attention, and executive function.3 50200, Thailand. E-mail: [email protected] Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 427
However, cognitive training is an alternative non- random diffusion as measured by the apparent diffusion pharmacological treatment used among the elderly coefficient (ADC) index. The DTI revealed the impaired with MCI 4 to promote the decrement of severity of integrity of white matter in the cingulum and fornix in MCI. The cognitive training program was effective in individuals with MCI and correlated with impairment of improving visual and auditory attention and memory.5 verbal episodic memory and delayed verbal memory of The memory strategies training encourage elaborative words.15 encoding of recalled information and a level Therefore, this study was to pilot the use of DTI of processing which enhances retrieval and memory as an outcome measurement to determine white matter performance.6 Another non-pharmacological treatment, integrity changes in brain area that involved episodic the multisensory stimulation (MSS) is a specifically memory; the cingulum, fornix, corpus callosum and designed environment and equipment to stimulate the the uncinated fasciculus in elderly with cognitive senses of sight, hearing, touch, and smell.7 MSS is impairment during the multimodal episodic memory beneficial to mediate positive effect on mood, behavior, training that encompasses group-based memory training cognition, and functional performance.8 Additionally, activities, multisensory stimulation, and mindfulness- the mindfulness-based yoga training is associated with based yoga training. a physical yoga discipline, results in both awareness and focused attention, which improves attention and memory Materials and methods performances of cognitive functioning.9 Furthermore, the benefits of cognitive intervention combined with Participants other promising non-pharmacological interventions The community-dwelling elderly were recruited like the multi-facet cognitive program including from members of the Nong-Kwai elderly school in a mindfulness, yoga, physical activity, art therapy, music suburban municipal district, Chiang Mai, Thailand. therapy resulted in cognitive performance improvement Participants were included if they were aged between 60- in patients having mild Alzheimer’s disease and mild 80 years and had no depressive symptoms as determined cognitive impairment.10-11 by the Thai Geriatric Depression Scale (TGDS).16 The age-related diseases correlated with the brain Participants were excluded if they had a previous structural and neuronal dysfunction with disturbances of diagnosis of either dementia, Alzheimer’s disease, or brain white matter structure may produce disconnections any cerebrovascular accident, and they reported having of cortical regions and result in age-related cognitive claustrophobia or had contraindication to magnetic declines.12 In addition, the structural abnormalities resonance imaging (MRI) scanning. The Thai Mental 17 of the fornix correlated highly with declarative and State Examination (MSET10) was used to measure episodic memory performance. This structure appears to the general cognitive function for descriptive purposes provide a robust and early imaging predictor for memory and the Kendrick Assessment Scales of Cognitive 18 deficits because the fornix is a part of the limbic system Ageing (KASCA) was used to determine the level and constitutes the major efferent and afferent white of cognitive function. Twenty elderly with cognitive matter tracts from the hippocampus.13 The neuroimaging impairment group who had the MSET10 scores of 19-23 studies with diffusion tensor imaging (DTI) having points and KASCA scores below 11 points. They were specially designed gradient schemes in the diffusion assigned into the experimental group (n=10) if they had weighted magnetic resonance imaging (MRI) method, received multimodal episodic memory training, and the have been applied to examine the subtle microscopic waiting-list control group (n=10). The study protocol interruptions and loss of white matter integrity.14 DTI conformed to the ethical guidelines of the Declaration is capable of measuring directionally restricted water of Helsinki as reflected in an a priori approval by the diffusion in brain tissue. Microscopic changes of axonal institution’s human research committee. All participants loss and demyelination alter the intact white matter fiber had given individual consent prior to taking part in the bundle and lead to a reduction of directionally restricted study. water diffusion as indicated by the fractional anisotropy (FA) index, while there is a corresponding increase in 428 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Research instruments identifying the white matter tractography by regions of interest (ROI) analysis. The axial, coronal, and sagittal The neuroimaging study was obtained by using lines can be selected to reach the anatomical pathway of magnetic resonance imaging (MRI), which was the desired nerve fibers by fiber tracking. After that, the performed using an automated single-voxel with Philips image-processing program creates a two-dimensional Achieva 1.5 Tesla units (Philips healthcare, UK) 19 image of the nerve fibers depending on the FA and voxel equipped with head coils. of the similar diffusion directions.21 The Quantitative The multimodal episodic memory training protocol data parameters of white matter tractography were FA (MEMT protocol) 20 was designed to be conducted for (fractional anisotropy) or diffusion constant and ADC 36 sessions (3 days per week for 12 consecutive weeks), (apparent diffusion coefficient) in square millimeters 2 lasting for about 90 minutes per session. Each MEMT per second (mm /s). The FA index is a useful measure protocol session started with multisensory stimulation of connectivity in the brain that can be derived from using sensory equipment within relaxing environment the diffusion tensor imaging (DTI) dataset. The ADC together with mindfulness-based Yin yoga practice for is a measure of the magnitude of diffusion (of water 30 minutes in a multisensory room. This was followed molecules) within tissue, and is commonly clinically by practicing episodic memory activities; group-based calculated using MRI. This is referred to as the mean activities in a variety of paper-based or tabletop activities, diffusivity. All images were transferred to workstation and memory strategies training for 60 minutes. (Phillips Extended MR Workspace 2.6.3.2) and analyze with Philips Fibertrack module. Procedure Data Analysis All participants were scanned with MRI at 1 week before the beginning of the MEMT training and post- The demographic data of the participants used assessment after finished the 36-sessions of MEMT descriptive statistics. In addition, the comparisons of the protocol training at the MRI Center, Faculty of Associated differences between the FA and ADC mean values of Medical Sciences, Chiang Mai University. The targeted the white matter integrity in each brain region (corpus brain regions were corpus callosum, fornix, cingulum, callosum, fornix, cingulum, and uncinate fasciculus) and uncinate fasciculus. The MRI scan time was set at between the elderly with cognitive impairment groups 10.44 minutes. A T1-weighted images in axial, sagittal, were analyzed by using the Mann-Whitney U test. and coronal planes were obtained for localizing the MRI Results voxels. For diffusion tensor imaging (DTI) acquisition, diffusion-weighted images were collected using 1.5 Tesla The participants almost equal distribution of gender, MRI scanner and the spin-echo echo-planar imaging age, and education between the control group, and the sequence. The parameters used in DTI protocol were set MEMT training group (Table 1). TDGS scores among as with repetition time (TR) of 15761 ms, an echo time all participants were less than 4-points that revealed no (TE) of 80 ms, field of view (FOV) of 224 mm, image depressive symptom. The cognitive screening scores of matrix of 112 x 110 mm, and slice thickness of 5 mm. the KASCA assessment reported mild cognitive function For high-resolution, anatomic brain scans were used for grades (score was below 11-points) in the control and MEMT training groups. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 429
Table 1: Demographical characteristics of the participants
The DTI tractography analysis of brain regions in (control group) (Table 2). However, in the MEMT both group of elderly with cognitive impairment that training group between pre- and post-intervention, it was include the corpus callosum, fornix, cingulum, and revealed that the FA means scores in both sides of the uncinate fasciculus revealed the white matter integrity uncinate fasciculus showed a p value of (p=0.06) on the with the FA and ADC values. There are no significant right side and in the left side it was (p=0.08) which is differences (p>0.05) in the FA means scores in all targeted close to a being a significant level (p=0.05). Moreover, brain regions between pre- and post-intervention among Figure 1 illustrated the FA value plot of the uncinate the elderly with cognitive impairment who received the fasciculus brain region in the MEMT training group 36 sessions training of the MEMT protocol (MEMT between pre-and post-MEMT training. training group) and those that did not receive training
Table 2: Comparison of FA data between pre- and post- MEMT protocol training in waiting-list control and MEMT training group
430 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
(A) (B)
Figure 1: FA data of right (A) and left (B) uncinated fasciculus between before (blue line) and after (red line) MEMT protocol training in MEMT training group In addition, there are no signifi cant differences (p>0.05) in the ADC means scores in all targeted brain regions between pre- and post-training in both groups (Table 3).
Table 3: Comparison of ADC data between pre- and post-training in waiting-list control and MEMT training group Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 431
Discussion cerebral blood flow correlates of the cognitive gains. They propose that cognitive training enhances resting- This study explored the brain areas associated with state neural activity and connectivity while it increases episodic memory including the corpus callosum, fornix, the blood supply to these regions via neurovascular cingulum, and the uncinated fasciculus among elderly coupling. with cognitive impairment who had received and not received the 36 sessions of MEMT protocol training. Nevertheless, the changes of FA and ADC values The quantitative data from visualization using the did not reach significant levels in the current study. DTI technique determined the white matter integrity, Training may merely induce regional anatomical diffusion of nerve fibers with the FA (fractional changes without creating structural alternation of white anisotropy) values, and the measurements of the size of matter microstructures.24 In addition, increased FA show diffusion of nerve fibers with ADC (apparent diffusion preserved white matter microstructures and optimized coefficient) values. The white matter integrity indicated signal transmission as a compensatory or restorative by the FA values in pre-MEMT and post-MEMT training mechanism designed to improve neural connectivity (Table 2) demonstrated no significant difference of FA that is resilient to training-induced neurocognitive of all targeted brain regions in elderly with cognitive plasticity.25 Additionally, the DTI technique has possible impairment between two groups. In addition, the notable benefits for determining white matter pathological findings of FA values in uncinated fasciculus brain alteration underlying cognitive changes occurring in region in MEMT training group revealed the closure older adults. to the significant level (p=0.05) and the white matter integrity indicated by the ADC value (Table 3) showed Conclusion no significant difference between elderly with cognitive After 36 sessions of MEMT training, the quantitative impairment in all targeted brain regions. Notably, the data from MRI regarding the white matter integrity with tendency of means scores of FA and ADC value are also either FA values or ADC values in all targeted brain small differences among the groups. regions showed no statistically significant differences. The separately plotted line graph of each 10-targeted However, the uncinated fasciculus revealed a tendency participant of MEMT training group (Figure 1) shows the of changes with the FA values showing slight increases. tendency of FA values to be higher on both sides of the This finding showed close association to the anatomical uncinate fasciculus. These results suggested that after 36 considerations of changes that took place in white matter sessions of the MEMT protocol training the uncinated integrity after training. fasciculus could be opposed to anatomical change. Acknowledgements: We wish to thank the elderly These results explained aspects of the components of the school members at Nong-Kwai municipal district, MEMT protocol in this present study: memory strategies Chiang Mai province, Thailand for their willingness to that include cues guidance (verbal and physical prompt), participate in this study. rehearsal, and learning association of objects. These strategies could promote the availability of neuronal Conflicts of Interest: These authors state that they connectivity of uncinated fasciculus information flow have no conflicts of interest. that allows the orbitofrontal cortex to rapidly modulate Ethical approval: The study was approved by the mnemonic representations stored in the temporal institution ethics committee. lobe to interact with learn associations and guide decision making in the frontal lobe to perform tasks. Source of Funding: This work was supported by 22 In addition, the present study also is consistent with the research fund for graduate studies of The Faculty 23 Chapman and colleagues who suggested that the 12- of Associated Medical Sciences, and the Chiang Mai week strategy-based cognitive training in older adults University research grant, Chiang Mai University, resulted in increased FA of white matter integrity in Thailand. the left uncinated fasciculus and resulted in cognition improvements that were identified along with significant 432 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
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Sevia Rani Irianti1, Anggi Lukman Wicaksana2, Heny Suseani Pangastuti2 1Student, School of Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (UGM). 2Assistant Professor, Department of Medical Surgical Nursing, Faculty of Medicine, Public Health, and Nursing, UGM
Abstract Objective: To test the validity and reliability of the Indonesian version of diabetes quality of life-brief clinical inventory (DQoL-BCI).
Methods: A cross-cultural adaptation was performed using forward and backward translation. Validity and reliability tests were conducted at Public Health Center (PHC) in Yogyakarta with 75 adult type 2 diabetes (T2D) patients. Content validity and construct validity were conducted. The reliability test was assessed by internal consistency.
Results: The average age was 60years and most respondents were female with high school education and unemployment. The results showed content validity index (CVI) score were 0.80-1.00 and 0.90 for item and scale, respectively. The correlation among items indicated moderate association (r = 0.255-0.581). The EFA resulted in the KMO 0.633, Bartlett test 310.604, p = 0.000, and total variance of explained QoL was 64.22%. Cronbach alpha of the Indonesian version of DQoL-BCI was 0.735, indicated adequate result.
Conclusion: The Indonesian version of DQoL-BCI is a reliable and valid instrument to assess health related quality of life on T2D patients.
Keyword: DQoL-BCI, diabetes mellitus, validity, reliability, quality of life
Introduction The DQoL-BCI is available in several languages such as Malaysian2, Iranian3, Polish4 and Greec5, but Diabetes quality of life (DQoL) is a specific and it is not available in Indonesia. Before the application common tool to measure quality of life (QoL) among in specific diabetes patients, the instrument should diabetic patients. Due to the illness progress, the be tested for validity and reliability. A psychometric instrument was developed in a short, but valid inventory, testing is essential during development or adopting an known as the DQoL-BCI. The questionnaire was instrument6. Only a valid and reliable tool can guarantee conceptualized from several diabetes QoL instruments an appropriate and trustable outcomes7. To our best and made in a shorter version to minimize the filling knowledge, there is no a cross-cultural adaptation study time. The DQoL-BCI consists of 15 questions and is of DQoL-BCI in Indonesia. Therefore, a methodological 1 useful for clinical practice and research . study is required to check the validity and reliability of the DQoL-BCI in Indonesian version. The purpose of this study was to identify the validity and reliability Corresponding author: indicators of the Indonesian version of DQoL-BCI on Anggi L. Wicaksana, Ismangoen Bd. 2F, Jl. Farmako, diabetic patients. Sekip Utara, UGM Yogyakarta, Indonesia, 55281. E-mail: [email protected] Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 435
Methods dieticians, and nursing faculty, reviewed the Indonesian and original version. A content analysis recommends Design and samples inviting three to ten multidisciplinary experts in a A quantitative research using cross-sectional design panel11. The procedure of evaluating the content validity was conducted between August-September 2018. to gain CVI for scale and item was similar with previous Adult T2D patients were invited to participate using study12,13. The outcome of expert review was then piloted consecutive sampling technique. The included criteria to 10 T2D patients in one PHC in Yogyakarta to check were native Indonesian and agreed to join a study. readability and estimated time for accomplishment. Meanwhile, the T2DP who had mental problems were The final version of Indonesian DQoL-BCI was excluded. administered in two PHC units to test construct validity The minimum samples for the cross-cultural study and internal consistency. The nurse in charge provided was at least five participants in each item8. There are 15 a list of T2D patients who participated in diabetes items in DQoL-BCI and then researchers require a total meeting–known as Prolanis. All T2D patients were of 75 participants for validity and reliability testing. screening using inclusion/exclusion criteria and eligible patients received research information. Then, they Measurement were requested to sign if they agree to join the study. The DQoL-BCI was developed by Burroughs et Researchers provided a time for participants to self fill- al.1 to assess the QoL in patients with T1D and T2D. in the questionnaire and directly returned in a closed The researchers provided an approval for translation envelop after completion. from the original authors9. The DQoL-BCI consists of Data Analysis 15 questions. Each item in the DQoL-BCI has a 5-point Likert’s scale (1=Very Dissatisfied/All the Time, An IBM SPSS for Windows version 15.0 was used 2=Moderately Dissatisfied/Often, 3=Neither/Sometimes, to test validity and reliability. Researchers tested the 4=Moderately Satisfied/Very Seldom, 5=Very Satisfied/ content and construct validity and internal consistency Never). For sake of analysis, a minimum of two-third for reliability test. Item and scale CVI were identify (10 out of 15) of total items should be completed1. The adequate when the outcome indicated ≥ 0.80 and ≥ final score of the DQoL-BCI was obtained by calculating 0.90, respectively, for less than 6 experts in expert the average score of total items. The possible range is judgment11,13. The construct validity used Pearson between 1 and 5, in which number 1 shows the lowest product moment test and the exploratory factor analysis QoL of diabetic patients and number 5 shows the highest (EFA). The results of Pearson test were compared QoL. The higher number of obtained values indicates a with r table to indicate the valid/non-valid items14. better QoL1,9. The EFA was applied using the principal component analysis (PCA) with Varimax rotation as following Procedures for data collection the construct of instrument. The Keiser-Meyer-Olkin (KMO) and Bartlett test were assessed and only factor A cross-cultural adaptation process was applied loading ≥ 0.32 was proceeded12. Internal consistency using a guideline of Beaton et al.10 which consists of using Cronbach’s Alpha coefficient was used to indicate 5 stages; forward translation, synthesis, backward reliable questionnaire. Alpha coefficient ≥ 0.70 indicates translation, expert review, pilot testing and validity/ acceptable internal consistency11-13. reliability test. First, the DQoL-BCI was independently forward translated into Indonesian version by two Results bilingual (English-Indonesian) speakers. Secondly, the researchers synthetized forward translation results. Next, A total of 75 participants in this study and the two English native speakers who understand Indonesian, characteristics were mostly females (65.3%), with senior back translated questionnaire into English version. Five high school or above education (53.4%), unemployed multidisciplinary experts on diabetes, consisting two (61.3%), and the average age was 60 (± 8.46) years. internal medicine nurses, consultant endocrinologist, 436 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
The items CVI resulted a range between 0.80-1.00 for the responses. and the scale CVI was 0.90. The experts suggested Moreover, the expert advised to provide an modifying the sequence of questions regarding the type explanation and examples for several items (1, 2, 4, 5, 6, 7, of responses. We modified the original question order 13, and 14) of Indonesian DQoL-BCI beside the original to Indonesian DQoL-BCI (#3→#10, #4→#11, #5→#3, question to avoid confusedness during completing the #6→#4, #7→#12, #8→#5, #10→#13, #11→#6, questionnaire because it was self-reported questionnaire #12→#14, #13→#15, #14→#7, #15→#8, item no (Table 1). The pilot testing on 10 respondents indicated #1, #2, and #9 were in the same order). The first eight that they all agreed that the instrument was easy to questions used responses of very satisfied, satisfied and understand and required an 11 minutes to complete. soon while the rest items used never, very seldom etc.
Table 1. Further explanation and examples of Indonesian version of DQoL-BCI
No Explanation and examples
Diabetes treatment includes physical activity, diabetes education, medication, smoking cessation, avoiding alcohol, #1 maintaining a diet and monitoring blood sugar.
To manage diabetes, it is required proper diabetes management. This activities can be carried out in PHC, NCD #2 community services or the nearest health care facilities.
Exercise shoul acomplish for at least 150 minutes/week with moderate intensity i.e. cycling, jogging, walking, brisk #4 walking or aerobic.
Diabetes can cause sexual problems. Male diabetes patients could have erectile dysfunction and premature #5 ejaculation while females have problems on unstable sexual mood, orgasm, and itchying in genital area.
Diabetes treatment can be a family burden. It icludes more time, energy, costs, thoughts and feelings related to #6 diabetes management.
#7 Diabetes checkups include blood sugar monitoring, regular, foot, eyes examinations and others.
#13 Pain related to diabetes treatment is resulted by insulin injection, collecting blood samples, and diabetic wound care.
#14 Physically ill includes pain, heat, fever, tingling, body discomfort due to treatment and management of diabetes
The r table was determined as 0.227 and the outcome of Pearson test showed r= 0.255-0.581, indicated greater results if it compared with the r table. The EFA result in the KMO 0.633, Bartlett test 310.604, and p = 0.000. Total variance of explained QoL was 64.22% (Table 2). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 437
Table 2. Factor loading of Indonesian version of DQoL-BCI
Item #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15
Loading 0.58 0.71 0.68 0.54 0.58 0.72 0.72 0.53 0.67 0.63 0.43 0.74 0.69 0.67 0.72
AIC 0.62 0.79 0.60 0.59 0.75 0.61 0.68 0.72 0.61 0.50 0.53 0.70 0.46 0.70 0.53
Total cumulative variance for extraction sum of squared loadings 64.22%
Total cumulative variance for rotation sum of squared loadings 64.22%
AIC=anti-image correlation
The Cronbach Alpha coeficient for the Indonesian the example for specific terminology (i.e. diabetes pain DQoL-BCI was 0.735. The correlation for inter-item due to insulin injection, collecting blood samples, and and item-total were -0.233 to 0.578 and 0.124 to 0.463. diabetic wound care). Then, there was no question among the 10 respondents in pilot phase. The filling time Discussion on Indonesian version of DQoL-BCI was quite similar This study highlights the validity and reliability with the Malaysian2 and Iranian version3, in which they outcomes of the Indonesian version of DQoL-BCI. required 10-15 minutes to complete the questionnaire. It Our study finding indicated the acceptable outcome of is relatively short time in filling a full questionnaire and psychometric testing for Indonesian version of DQoL- makes the DQoL-BCI applicable in clinical settings as BCI among Indonesian T2D patients. The findings of well as research purpose1,9. CVI for Indonesian version of DQoL-BCI were similar The EFA results of the Indonesian version of with Iranian3 and Greek version5. In Iranian version, DQoL-BCI showed acceptable outcomes with explained the review of six experts resulted item CVI value in variance of 64.22%. It is unsurprisingly because the the range of 0.78-0.94, scale CVI of 0.84, and content previous methodological studies in Iranian3 and Greek5 validity ratio (CVR) of 1.0083. On the other hands, the diabetes patients indicate the similar trend. The Iranian Greek version of DQoL-BCI indicated that item CVI version of DQoL-BCI showed higher KMO value scores were between 0.73 and 1.00, scale CVI was 0.87 (0.712) and resulted the three factors. This version of and CVR was 1.007 after five diabetes expert review5. DQoL-BCI also confirmed that there were three construct The pilot testing on 10 diabetic patients showed a factors in DQoL-BCI; (a) diabetes complication, (b) full agreement that the Indonesian version of DQoL-BCI therapy, follow up, and diagnosis, and (c) psychosocial is understandable and required an average of 11 minutes effect of diabetes, and indicated adequacy results of the for filling all items. The full agreement was achieve three constructed factors3. The three construct factors because the DQoL-BCI was added by addendum and were also found in the Greek version of DQoL-BCI with 438 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
the total explained variance was 82.7%. This version of Diabetes Quality of Life Brief Clinical Inventory. DQoL-BCI indicated relatively higher variance of QoL Diabetes Spectrum. 2004;17(1):41–49. among diabetic patients if it was compared with the 2. Samah S, Neoh CF, Wong YY, et al. Linguistic Indonesian version of DQoL-BCI. The factors loading in and psychometric validation of the Malaysian the Greek version were between 0.352 and 0.9445. In our version of Diabetes Quality of Life-Brief Clinical study, we identify a moderate loading factors among the Inventory (DQoL-BCI). Research in Social and items (0.43-0.74) and all items showed greater numbers Administrative Pharmacy. 2017;13(6):1135–1141. than the standard of loading factor (0.32) in EFA12. 3. Mirfeizi M, Jafarabadi MA, Toorzani ZM, et al. Feasibility, reliability and validity of the Iranian The internal consistency outcome of the Indonesian version of the Diabetes Quality of Life Brief Clinical version of the DQoL-BCI instrument was 0.735. It Inventory (IDQOL-BCI). Diabetes Research and showed that this instrument was consistent and reliable Clinical Practice. 2012;96(2):237–247. for measuring the quality of life in people with T2D with 4. Dudzińska M, Tarach JS, Zwolak A, et al. Type 2 an acceptable result. The results of the alpha coefficient diabetes mellitus in relation to place of residence: 11-13 in this study was relatively lower, but acceptable , Evaluation of selected aspects of socio-demographic than the original version which had an alpha 0.855. The status, course of diabetes and quality of life - a outcome of alpha coefficient in Indonesian version of cross-sectional study. Annals of Agricultural and DQoL-BCI was quite closer with other version of DQoL- Environmental Medicine. 2013;20(4):869–874. BCI questionnaires. The Malaysian, Iranian, Polish, and 5. Rekleiti M, Souliotis K, Sarafis P, Tsironi M, Greek version indicated coefficient alpha were 0.7032, Kyriazis I. Measuring the Reliability and Validity 0.7583, 0.7614, and 0.9575, respectively. All the versions of The Greek Edition of the Diabetes Quality of showed the reliable outcome of the DQoL-BCI after Life Brief Clinical Inventory. Diabetes Research conducting a cross-cultural adaptation process. and Clinical Practice. 2018. 6. Kimberlin CL, Winterstein AG. Validity and Conclusion reliability of measurement instruments used in The Indonesian version of the DQoL-BCI is reliable research. American Journal of Health-System and valid tool for assessing the QoL of Indonesian T2D Pharmacy. 2008;65: 2276-2284. patients. Further methodological research should be 7. Wan TTH. Evidenced-Based Health Care conducted among T1D patients. Researchers, nurses and Management. Multivariate Modeling Approaches. other health workers can utilize the tool in measuring Norwell, MA: Kluwer Academic Publishers. 2002. health related QoL for diabetic patients. 8. Pett MA, Lackey NR, Sullivan JJ. Making sense factor analysis. The use of factor analysis for Conflict of Interest: None instrument development in health care research. Thousand Oaks, CA: Sage Publications Inc; 2003. Funding: The faculty of Medicine, Public Health, 9. Noviyantini NPA, Wicaksana AL, Pangastuti HS. and Nursing, UGM, provided a grant for young research Kualitas Hidup Peserta Prolanis Diabetes Tipe 2 di project in 2018. Yogyakarta. Jurnal Persatuan Perawat Indonesia. Acknowledgements: The authors would 2019;4(2):98-104. acknowledge all T2D patients who joined this study 10. Beaton DE, Bombardier C, Guillemin F, Ferraz and the nurses in PHC for facilitating the data collection BM. Guidelines for the Process of Cross-Cultural process. Adaptation of Self-Report Measures. SPINE. 2000;25(24):3186-3191. Ethic Statement: This study received approval 11. Polit DF, Beck CT, Owen SV. Is the CVI an from the institutional review board of UGM. Acceptable Indicator of Content Validity? Appraisal and Recommendations. Research in References Nursing & Health. 2007;(30):459-467. 1. Burroughs TE, Desikan R, Waterman BM, Gilin 12. Wicaksana AL, Wang S. Psychometric Testing of the D, McGill J. Development and Validation of the Indonesian Version of Dietary Sodium Restriction Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 439
Questionnaire Among Patients with Hypertension. short form 12 version 2 among patients with Asian Nursing Research. 2018;12:279-285. cardiovascular diseases. International Journal of 13. Wicaksana AL, Maharani E, Hertanti SH. The Nursing Practice. 2020;26(2):e12804. Indonesian version of the medical outcome survey- 14. Nugroho AN. Strategi Jitu Memilih Statistik Penelitian Dengan SPSS. Yogyakarta: Penerbit ANDI. 2005. 440 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13886
The Effect of Virgin Coconut Oil (VCO) with Lotion on the Skin Moisture among Uremic Patients Undergoing Hemodialysis
Siti Saodah1, Imam Budi Putra2, Cholina Trisa S3 1Master Student, Faculty of Nursing, Universitas Sumatera Utara, Indonesia, 2 Lecturer, Faculty of Medicine, Universitas Sumatera Utara, Indonesia, 3Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Indonesia
Abstract Objects: to examine the effect of Virgin Coconut Oil on the skin moisture among uremic patients undergoing hemodialysis.
Methods: the study was a quasi-experiment with a pre-test and post-test equivalent control group. The study population was 80 persons.
Results: The results showed that there was a significant effect of skin moisture on the intervention group before and after being given Virgin Coconut Oil. Data were analyzed by pair t-test and independent test.
Conclusion: There is no need for special emulsions such as Virgin Coconut Oil to moisturize the skin in uremic patients undergoing hemodialysis because of using ordinary lotions can moisturize the skin, but it must be used regularly, twice a day after bathing, the lotion used must also be a lotion that does not contain mercury as well as chemicals that can harm the skin.
Keywords: Virgin Coconut Oil; Lotion; Uremic Patients; Hemodialysis; Skin Moisture
Introduction which affects 50% -90% of patients with peritoneal dialysis or hemodialysis. until severe according to the Chronic Kidney Disease (CKD) is a public health final stage of kidney disease(5). problem worldwide. According to the United States, the prevalence of kidney failure is increasing by 20- According to Specchio, Carboni, Chimenti, Tamburi, 25% every year(1). It is estimated that more than 20 and Nisticò(6) said that 80% of 100 hemodialysis million (more than 10%) of adults in the United States patients complained of skin problems with general experience CKD annually. CKD is increasing by more findings of xerosis 79%, pale 60%, pruritus 53%, and than 50% in the world annually. In the United States, skin pigmentation 43%. Impaired skin integrity is a very Patients with acute kidney failure hospitals increased disturbing problem in patients with end renal failure from year to year by 4.9% in 1983; 7.2% in 2002; 20% undergoing hemodialysis(7). Pruritus or itching is the in 2012(2). most common symptom of advanced kidney disease. For patients with chronic kidney failure, 15-49% experience CKD is caused by a decrease in kidney function and pruritus, and those who undergo dialysis 50-90%. Acute the accumulation of protein metabolic residues called renal failure, pruritus is very rare. The prevalence is uremic toxics(3). Uremic develops more frequently with slightly greater in hemodialysis patients at 42% and in chronic kidney disease but can also occur with acute peritoneal dialysis patients at 32%(8). kidney failure if the loss of kidney function is rapid(4). One of the problems that often arise in CKD is skin The skincare, first by keeping the skin clean and dry, integrity disorders such as itching (pruritus), dry skin uses a skin cleanser with a balanced pH(9). One of the (xerosis), and skin discoloration (skin discoloration) interventions in maintaining the integrity of the skin is Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 441
providing lubricant moisturizers such as lotions, creams, Procedures and ointments, low alcohol or protective skin barriers The study was conducted at the Hemodialysis unit such as liquid barrier films, transparent films, and in dr.RM. Djoelham Binjai Hospital from April to May hydrocolloids. Skincare using a moisturizer (moisturizer) 2018. Ethical Committee of Faculty of Nursing Sciences is believed to be an inexpensive action, does not cause of the University of Sumatera Utara then after research harm, and allows it to be implemented but the advantages permission permit received from Research Directorate and effectiveness of specific topical ingredients which of dr. R.M. Djoelham Binjai hospital. Intervention are simpler cannot yet be explained(10). group: 1) Pre-intervention: assess skin moisture before Virgin Coconut Oil (VCO) is believed to be good treatment; describes the VCO application protocol; for skin health because it is easily absorbed by the prepare the VCO to be used, 2) intervention: distribute skin and contains vitamin E(11). VCO contains natural VCO five minutes before action; explain the VCO moisturizers and helps maintain skin moisture and application protocol again; before the action is carried is good for dry, rough, and scaly skin. VCO contains out the researcher teaches the patient’s family how to medium-chain fatty acids (MCFA) that easily enter give VCO for the treatment of actions at home, before the deep skin layers and maintain skin elasticity and the action is carried out the respondent is recommended suppleness(12). The study was conducted by Noor, Aziz, to first clean the skin in the predetermined parts, namely Sarmidi, and Aziz (13)found that moisturizing lotions on the face, back of the hands, hands and feet while with VCO-SLPs containing virgin coconut oil of 20% being given massage; the action of applying VCO is were to be effective in increasing skin moisture and carried out twice a day after bathing; observing the increasing skin elasticity. There was a 24.8% increase in action using the observation sheet given to the client and skin moisture for lotions with VCO-SLPs compared to family, if the patient performs according to the protocol, a 12.7% increase in skin moisture. The study aimed to a checklist (√) is marked on the observation sheet, but if determine the effect of Virgin Coconut Oil on the skin the patient does not follow the protocol, a strip is marked moisture of uremic patients undergoing hemodialysis. (-) on the observation sheet, 3) Post-intervention: assess the patient’s skin moisture on day 1 to day 28 after VCO Methods administration. Design Research instrument A quasi-experimental study design pre-posttest with Skin moisture analyzer is an electronic digital tool a non-equivalent control group was applied in this study. that can be used to determine skin moisture. This tool Participants has the main use in determining the moisture value of human skin. With an assessment of ≤33% = very dry Eighty persons were selected by consecutive skin, with a value of 34-37% = dry skin, with a value sampling who met the following criteria, namely: (a) of 38-42% = normal skin. Measurements are made by patients with dry skin undergoing hemodialysis; (b) age gently pressing the tip of the skin moisture analyzer on ≥ 40 years; (c) performing routine hemodialysis modality the skin of the patient’s hands and feet. Leave this tool therapy for more than 6 months; (d) patients and families on the skin until the tool is done detecting. Once the tool can communicate and read and write in Indonesian; has fully detected, there is a beep and the screen will and (e) willing and willing to cooperate in conducting show the result as a percentage (%). research (which is shown by filling in the width of the participant’s agreement). Exclusion criteria, namely: (a) Data analysis didn’t use moisturizer in the last 2 weeks; (b) have a Data analysis was conducted to determine skin history of mental disorders; (c) orientation disturbances; moisture after being given VCO to both groups pre and and (d) treatment using psychotropic drugs. post using statistical analysis paired t-test. Meanwhile, to see differences in skin moisture after treatment between the intervention group and the control group 442 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 using statistical analysis independent t-test.
Results Table 1. frequency distribution of respondents by characteristics (n=80)
Intervention Control No Characteristics n=40 %(100) n=40 %(100)
Age: 1. a. <47 years old 25 62.5 23 57.5 b. >47 years old 15 37.5 17 42.5
Gender: 2. a. Male 20 50 18 45 b. Female 20 50 22 55
Education: a. Elementary school 07 17.5 08 20 3. b. Junior school 15 37.5 16 40 c. High school 11 27.5 10 25 d. University 07 17.5 06 15
Occupation: a. Labor 12 30 14 35 b. Teacher 07 17.5 03 07.5 c. Housewife 06 15 08 20 4. d. Farmers 10 25 12 30 e. Indonesian State Army 04 10 00 00 f. Civil servants 01 02 03 07.5 g. Entrepreneur 00 00 00 00
Marriage Status: 5. a. Single 04 10 03 07.5 b. Married 36 90 37 92.5
Lama HD : 6. a. < 2 years 31 77.5 33 82.5 b. > 2 years 09 22.5 07 17.5 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 443
Table 1. shows that the majority of respondents 40%. The majority of respondents in the intervention in the intervention group were <47 years (62.5%), group worked as laborers 30%. 35.% Based on marital as well as respondents in the control group, were <47 status, the majority of respondents in the intervention years (57.5%). In the intervention group, there were group were not married 52.5%, while the majority of 50% of the men and women respectively, while the respondents in the control group were married 75.0%. majority of the control group were women 55%. The The majority of respondents in the intervention group majority of respondents in the intervention group had underwent hemodialysis <2 years (77.5%), so did the a junior high school education at 37.5%, the majority majority of the control group underwent hemodialysis in the control group had a junior high school education <2 years (82.5%).
Tabel 2. distribution of respondents based on skin moisture before and after treatment (n=80)
Intervention Control
No. Skin Moisture Pretest Posttest Pretest Posttest
f % f % F % f %
1. Dry 40 100 0 0 40 100 0 0
2. Normal 00 0 25 62.5 0 0 38 95
3. Oily 0 0 15 37.5 0 0 2 5
Amount 40 100 40 100 40 100 40 100
Table 2. shows the skin moisture of the respondents in the intervention group before being given a VCO based on the category indicates that all of the respondents’ skin moisture was in the dry category, likewise the skin moisture of the respondents in the control group before being given a lotion also showed the same thing that all the respondents’ skin moisture was in the dry category. The results of skin moisture data analysis were normal in the intervention group respondents after being given a VCO 62.5%, a small proportion in the wet category 37.5%. Likewise, the skin moisture of respondents in the control group after being given lotion also showed the same thing that the majority of skin moisture respondents in the normal category were 38 persons 95%, a small portion in the wet category was 2 persons 5%.
Table 3. paired sample t-test results from the effect of skin moisture before and after being given a VCO
95%CI VCO Mean SD t-count p-value Lower Upper
Before 35.5 1.132 -8.818 -7.180 -19.748 0.000 After 43.5 2.837 444 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1
Table 3 shows that the value of t-count (-19.748) moisture after being given a VCO (posttest). A negative Table 4. paired sample t-test results in the effect of skin moisture before and after being given a lotion 95%CI Lotion Mean SD. t-count p-value Lower Upper Before 35.45 1.299 -5.177 -4.272 -21.134 0.000 After 40.17 1.838 Table 4. shows that the value of t-count (-21,134) Table 5. independent samples test tesults t-test the effect of viving VCO and lotion on skin moisture of uremic patients undergoing hemodialysis Group Mean St. Dev. std. Error Mean df t p Intervention 43.5 2.837 0.448 78 6.220 0.000 Control 40.1 1.838 0.290 Table 5. shows that the mean value in the intervention group (VCO) was 43.5 and the control group (lotion) was 40.1, this value meant the average skin moisture giving lotion is better than VCO, because by giving of uremic patients undergoing hemodialysis in the lotion more skin becomes normal, while using VCO the intervention group ( VCO) of 43.5 and the control group skin becomes more oily than giving lotion. (lotion) of 40.1. Thus it can be said that the skin moisture of uremic patients who underwent hemodialysis in the Discussions intervention group after being given VCO was higher CKD patients with hemodialysis have the side than the lotion. The results of paired sample t-test effects of discomfort in the form of skin disorders. analysis obtained t value> t table or 6.220> 1,664 at df Disorders of the skin such as itching, dry skin, and (degree of freedom) 78 and obtained a significant value striped/black skin. The cause of itching of the skin due of p = 0,000 <0.05, it means that there is an influence to dry skin, high levels of urea, calcium, and phosphate (difference) between the provision of VCO and lotion as well as increased levels of histamine and iron buildup, against the skin moisture of uremic patients undergoing this is caused because the kidneys cannot remove the hemodialysis. To increase skin moisture to be normal, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 445 remnants of metabolism(14). CKD patients undergoing continuous administration of Virgin Coconut Oil would hemodialysis (HD) have complex problems such as dry have a good effect on damage to skin integrity in chronic skin that often triggers uremic events. renal failure patients with visual analog scale (VAS) scores pre-intervention 8 (severe pruritus) and post- Based on the results of the study the skin moisture intervention 6 (moderate pruritus) so that this action is score in the intervention group (VCO) was 43.5 and an effective and efficient action for the patient(19). In in the control group was 40.1. Thus it can be said that another study at the ICU of Soedarso Regional Hospital the skin moisture of uremic patients who underwent Pontianak that based on observations obtained during hemodialysis in the intervention group after being the research, the researcher believes that there is an given VCO was higher than the lotion. The increase influence between the administration of VCO (Virgin occurred by 8%, before being given VCO, the average Coconut Oil) on pressure sores on the skin(19). skin moisture was 35.50% and after being given VCO it increased to 43.50%. Giving VCO which is done 2 times In line with research that the application of lotions a day ie morning and evening, in 2 weeks (14 days) on or moisturizers for 3 weeks on the skin of patients the face, back of hands, and feet can increase the skin with atopic dermatitis (DA) children has been proven moisture of uremia patients undergoing hemodialysis at to be effective in improving skin barrier (reducing the Regional General Hospital dr. RM. Djoelham Binjai. Transepidermal Water Loss/TEWL), significantly The majority of respondents who were initially in the improving skin dryness(20)(20)(20). In Malaysia found category of dry skin after being given intervention with that moisturizing lotion with VCO-SLPs containing 20% VCO the majority of respondents’ skin became normal virgin coconut oil was found to be effective in increasing and some were already moist. skin moisture and increasing skin elasticity(13). One of the traditional medicines that can be used There was a 24.8% increase in skin moisture for for the skin is virgin coconut oil. This natural material is lotions with VCO-SLPs compared to a 12.7% increase easily found around us, so it can reduce the number of in skin moisture. Research conducted on DM patients in costs that must be incurred and reduce the side effects Salatiga City Hospital about the effect of coconut oil on of drugs that will aggravate the kidney work of patients reducing itching showed that as many as 20 respondents with CKD(15). Antioxidant elements and vitamin E in experienced pruritus in the moderate category(21). VCO are used as a protective skin that can soften the Another study conducted on the scale of pruritus in skin(16). Virgin Coconut Oil also has advantages in terms patients with chronic kidney failure showed that as of the content of the medium-chain fatty acid (MCFA) many as 91 patients with chronic kidney failure who which is a component of medium-chain fatty acids that experienced pruritus with a moderate category(22). has many functions, including being able to moisturize dry skin. The use of VCO can reduce the risk factors for Conclusions pruritus such as dry skin to become moist on clients with The administration of Virgin Coconut Oil is no (17) chronic renal failure by hemodialysis . more effective in providing skin moisture for uremic patients in hemodialysis patients than lotions. This is This study is in line with Eka, Laily, Saragih, because VCO contains saturated fatty acids (saturated and Sirait(18) show an increase of 15.19% of foot skin fatty acids) which reach 90% whereas saturated fat moisture in the experimental group, and a decrease of content in marina lotion is only 55% so that the results 0.39% of foot skin moisture in the control group (only of the study using VCO in the intervention group of usual care, without intervention) it means that skin patients moreover moist than in the control group that moisture increases after being given virgin coconut oil, uses lotion. while those not treated get decreased skin moisture. Based on the independent sample t-test, there was a Conflict of Interest: Nil significant effect of virgin coconut oil on foot skin moisture. Research conducted in the Hemodialysis Source of Funding: No funding this is a study Room of Abdul Wahab Syahrin Hospital showed that Ethical Consideration: This research has passed the 446 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 test of ethics from the health research ethics committee 12. Tranggono RI, Latifah F. Buku Pengantar Ilmu of the Nursing Faculty of Universitas Sumatera Utara, Pengetahuan Kosmetik. Jakarta: Gramedia Pustaka with registration number 1630/II/SP/2019. Utama; 2013. 13. Norhayati MN, Azila AA, Roji SM, Ramlan A. References The effect of virgin coconut oil loaded solid lipid 1. USRDS. Annual Data Report [Internet]. 2013. particles (VCO-SLPs) on skin hydration and skin Available from: https://www.usrds.org/ elasticity. J Teknol (Sciences Eng. 2013;62(1). 2. James PA, Oparil S, Carter BL, Cushman WC, 14. Thomas R, Kanso A, Sedor JR. Chronic Kidney Dennison-Himmelfarb C, Handler J, et al. 2014 Disease and Its Complications. Prim Care - Clin Evidence-based guideline for the management of Off Pract. 2008;35(2):329–44. high blood pressure in adults: Report from the panel 15. Fauzi A, Setiawan I, Ariyanti F. The effect of members appointed to the Eighth Joint National Virgin coconut oil (VCO) on Staphylococcus Committee (JNC 8). JAMA - J Am Med Assoc. aureus infection in mice (Mus musculus) observed 2014;311(5):507–20. from different organ histopathology. J Appl Sci 3. Pardede SO. Pruritus Uremik. Sari Pediatr. Res. 2012;8(2):1168–73. 2016;11(5):348. 16. Price SA, Wilson LM. Pathophysiology: Clinical 4. Alper AB, Shenava RG. Uremia [Internet]. 2020. Concepts of Disease Processes. 6th ed. United Available from: https://emedicine.medscape.com/ State: Mosby; 2012. article/245296-overview. 17. Sutarmi S. Taklukkan Penyakit Dengan VCO. 1st 5. Gagnon AL, Desai T. Dermatological diseases ed. Jakarta: Penebar Swadaya; 2015. in patients with chronic kidney disease. J 18. Eka, Laily I, Saragih NP, Sirait LL. Pengaruh Nephropathol. 2013;2(2):104–9. penggunaan extra virgin olive oil pencegahan luka 6. Specchio F, Carboni I, Chimenti S, Tamburi F, tekan pada pasien berisiko dengan skala braden. Nisticò S. Cutaneous manifestations in patients 2019;153–8. with chronic renal failure on hemodialysis. Int J 19. Sari WNK, Ismahmudi R. Analisis Praktik Klinik Immunopathol Pharmacol. 2014;27(1):1–4. Keperawatan pada Pasien Gagal Ginjal Kronik 7. Shahgholian N, Dehghan M, Mortazavi M, Dengan Intervensi Inovasi Pemberian Virgin Gholami F, Valiani M. Effect of aromatherapy Coconut Oil (VCO) Terhadap Tingkat Keparahan on pruritus relief in hemodialysis patients. Pruritus yang Menjalani Hemodialisa di Ruang Iran J Nurs Midwifery Res [Internet]. Hemodialisa RSUD Abdul Wahab Sjahrine. 2018. 2010;15(4):240–4. Available from: http://www. 20. Herwanto N, Hutomo M. Studi retrospektif : ncbi.nlm.nih.gov/pubmed/22049288%0Ahttp:// penatalaksanaan dermatitis atopik (Retrospective www.pubmedcentral.nih.gov/articlerender. study : management of atopic dermatitis ). Berk fcgi?artid=PMC3203284 Ilmu Kesehat Kulit dan Kelamin. 2016;28(1):8–17. 8. Blaha T, Nigwekar S, Combs S, Kaw U, Krishnappa 21. Supriatna D, Dayatri Uray A, Astawan M, V, Raina R. Dermatologic manifestations in end Muchtadi D, Wresdiyati T. The Effect of VCO stage renal disease. Hemodial Int. 2019;23(1):3– Processing Method on Blood Glucose, Cholesterol 18. and Pancreatic Profile of Diabetic Mellitus 9. EPUAP. National Pressure Ilcer Advisory Panel Rats (Sprague Dawley). War Ind Has Pertan. [Internet]. 2014. Available from: https://www. 2018;35(2):91. epuap.org/ 22. Combs SA, Teixeira JP, Germain MJ. Pruritus 10. Moore ZEH, Webster J. Dressings and topical in Kidney Disease. Semin Nephrol [Internet]. agents for preventing pressure ulcers. Cochrane 2015;35(4):383–91. Available from: http://dx.doi. Database Syst Rev. 2018;2018(12). org/10.1016/j.semnephrol.2015.06.009 11. Utomo P. Apresiasi Penyakit Pengobatan Secara Tradisional Dan Modern. Cetakan 2. Jakarta: Rineka Cipta; 2012. DOI Number: 10.37506/ijphrd.v12i1.13887 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 447 Effect of Global Postural Re-Education and Static Stretching on Pain and Disability in Women with Chronic Non-Specific Neck Pain- A Comparative Study Sneha Somarajan 1 , Dr. Dharti Hingarajia 2 1Assistant Professor, Masters of Musculoskeletal sciences, The Shrimad Rajchandra College of Physiotherapy, Uka Tarsadia University, Maliba Campus, Bardoli, Gujarat, India, 2 Sr. Lecturer, Masters of Musculoskeletal and Sports, SPB Physiotherapy College, VNSGU, Surat, Gujarat, India Abstract Background: Women are more likely to develop and suffer from chronic non specific neck pain than men. Cervical muscle imbalance is considered an important factor to cause chronic non specific neck pain and disabilities during work, sport or daily activities. GPR is an option to manage postural deviations, treating aches and pains. The principal aim is to restore correct alignment of posture and re-establish body mechanics of the body movement to treat or prevent musculoskeletal problems. Objective: To Compare the effect of GPR and Static stretching on pain and disability in women with chronic non-specific neck pain. Methods: 64 female patients with chronic non-specific neck pain aged 18 to 35 years were randomly divided into two equal groups: GPR group and Static Stretching group. Both groups also received conventional therapy. Patients were evaluated before and after 4 week intervention for pain intensity (by means VAS), and for disability (by means of NDI). The treatment program consisted 3 sessions of 1-hour individual per week for 4 weeks. Data were statistically analyzed at a significance level of p<0.05. Conclusion: Statistically significant reduction in VAS and NDI were observed after 4 week intervention in both groups. However there were no significant differences observed between groups in this outcome measures. Global postural Re-education and Static stretching, in association to conventional therapy, were equally effective in reducing pain and disability in women with chronic non specific neck pain. Keywords: GPR (Global postural Re-education); chronic Neck pain; Static stretching, Physical therapy. Introduction persistent or regularly recurrent with duration of more than 3 months. In order of prevalence rate Overall, Pain is the most common symptom of which the 58.8% (95% CI, 54.8-62.7) of women and 47.2 (95% human kind complaints. Pain from musculoskeletal CI, 42.4-51.5) of men had experienced neck pain in the system is very common internationally in modern previous 6 months.1 sedentary society. Pain is defined as chronic when Manual therapy (MT) may decrease pain and Corresponding Author: muscle spasm and provide some degree of short- 2 Sneha Somarajan term NP relief, Manual therapy include stretching 3 Assistant Professor, the Shrimad Rajchandra College techniques for superficial cervical muscles. Static of Physiotherapy, Uka Tarsadia University, Maliba stretching is a commonly used method of stretching in Campus, Bardoli- Mahuva Road, Tarsadi- 394350, which soft tissues are elongated just past the point of Dist: Surat, Gujarat, India tissue resistance and then held in the lengthened position E-mail: [email protected], with a sustained stretch force over a period of time.4 Mobile no: +91- 8980360537 448 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 ‘Global Postural Re-education’ (GPR) is a physical groups by sealed envelope method. Group A: This was therapy method developed in France by Philippe consist of 32 patients and they had undergone GPR Emmanuel Souchard. It is based on a central concept and conventional. Group B: This was consisting of 32 that postural muscles are organized to act in concert patients and they had undergone Static Stretching and with each other as “muscle chains” located anterior and conventional. Before the beginning and after the 4 week posterior to the spine.1 It has been hypothesized that intervention period, all patients were evaluated in the specific clinical pre sensations are caused by “muscle following outcome measures. Pain measured in a 10 chain retractions” associated with Neck Pain.5 cm Visual Analog scale. VAS is a 10 cm line with pain descriptors marked “no pain” at 1 end and “the worst Global postural re-education aims to stretch and pain imaginable” at the other9. Disability measured by elongate these muscles, which are shortened state, by NDI scale. NDI scale is a questionnaire designed to help enhancing of antagonist muscles to promote improve us better understand how your neck pain affects your muscle balance and postural symmetry.6 Based on the ability to manage everyday life activities10.This same existence of muscle chain didactically divided into sequence was maintained throughout the study posterior and anterior chains,7 the method proposes global stretching of antigravity muscles. Interventions: Although the method is often clinically practiced, All the patients attended 1 hour 3 physical therapy very few studies were found on its efficacy in neck sessions per week for 4-week period. pain and its comparison with individual manual static GPR Group A: Patient in this group received stretching. In view of the incidence of neck pain and its muscle chains stretch as described by Marques keeping consequences, especially in women, the purpose of the two stretching postures for 15 minutes each11. present study was to compare the effects of two kinds of stretching, GPR and static stretching in relieving In order to stretch the posterior muscle chain pain and disability in female patients with non-specific (upper trapezius; levator scapule, suboccupiltalis, 8 chronic neck pain. erector spinae, gluteus maximus, ischiotibialis triceps surae & foot intrinsic muscles), the patient will lie in the Methodology supine position with the occipital, lumbar , and sacral An approval for the study was obtained from the spine stabilized, with lower limbs at 90˚ hip flexion and Institutional Ethical Committee. An Experimental study perform gradual knee extension. The posterior muscle was conducted in subjects with Women with chronic non- chain stretch: (A) Supine posture with leg flexion specific neck pain SPB Physiotherapy College, Surat. progression: posterior muscle strain stretching Starting Sample was achieved by Purposive sampling method. position. (B) Supine posture with leg flexion progression: A total of n=64 subjects were selected. All the subjects posterior muscle chain stretching Final position11 were screened for inclusion Criteria i:e,Volunteers from S.P.B Physiotherapy College were considered In order to stretch the anterior muscle chain for inclusion in the study if they met the following (diaphragm, pectoralis minor, scalene, sternocleido criteria:18-35 years of age of women, on specific neck mastoid, intercostalis, iliopsoas, arm, forearm and hand pain diagnosis by orthopedician, Pain lasting for over 3 flexes), the patient lies in the supine position with upper months, Patients with Neck Disability Index (NDI) score limbs abducted at 30˚ and forearms supine. The anterior less than 24/50. Subjects excluded History of significant muscle chain stretch: (A) Supine posture with leg trauma to the cervical spine, fracture and dislocation of extension progression: anterior muscle chain stretching cervical spine, history of Vertigo, Disease of spinal cord, Starting position. (B)Supine posture with leg extension Inflammatory or infective arthropatheis of the vertebral progression: anterior muscle chain stretching Final 11 column,Neurological signs and symptoms. Informed position consent for participation of subjects in the study will The pelvis will be kept in retroversion, while lumbar be obtained. Demographic data, BMI, of all the patients spine remains stabilized. Hips will be flexed abducted was recorded. They were randomly allocated in to two Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 449 and laterally rotated, with soles of feet touching each pack for (20minutes). other. Statistics Analyses Gradually, suspecting the patients limits, the lower Statistical analysis was done using SPSS version limbs will be extended as much as possible while 15software. Baseline characteristics were compared to maintaining the tibiotarsal angle at 90˚. check homogeneity between intervention groups. Paired Static Stretching Group B: t-test was used to analyze the pre and post intervention differences within each group and independent t-test Patients in this group received stretching of, was used for between groups comparison. Confidence 12 forearm supinators and paravertebral muscles. upper interval was kept 95% and the level of significance for trapezius, and back of the neck, pectrolis, major and all statistical data was set α =0.05. Total 64 patients were minor, rhomboids, finger and wrist flexors, and forearm recruited pronators. Each stretch was passively repeated twice for 30 seconds and done slowly at normal breathing rhythm Results and with no compensation allowed.The total stretching Total 82 patients were assessed for eligibility. Sixty time will be equivalent to that of the GPR group. four patients were enrolled in the study and randomized Conventional Protocol: to one of the treatment group (32 in GPR group and 32 in SS group). Mean age of participants in GPR was Conventional therapy was given for 30 minutes in 21.65±3.38, and of SS group was 26.43±6.07. For GPR each session.Repetitions and 10 sec hold and 2 minutes group Minimum Age was 19 and Maximum Age was rest period administered between each exercise. 30 and for SS Minimum Age was 20 and Maximum Exercises included were: Isometrics exercises of- Age was 35. One patient from GPR and two from SS Cervical flexors, extensors, lateral rotators (right and group discontinued intervention in between. Outcome left), side flexors (right and left).On neck region Hot measurements were completed on 61 participants (31 in the GPR group and 30 in the SS group) after 6 week of intervention. Table:1 Baseline characteristics of subjects GROUP A GROUP B VARIABLE P value Mean ± SD Mean ± SD AGE (Years) 21.65±3.38 26.43±6.07 0.62 BMI (kg/m2) 21.74±3.39 25.64±4.35 0.38 DURATION (Week) 13.10±1.59 15.30±8.93 0.18 PRE VAS (Cm) 4.53±1.15 4.81±1.21 0.36 PRE NDI 15.43±3.43 16.73±3.27 0.13 450 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 The GROUP A receiving GPR Intervention with mean age of (21.65±3.38) and mean pre VAS and pre NDI score of (4.53±1.15,15.43±3.43), GROUP B receiving GPR intervention with mean age of (26.43±6.07) and mean pre VAS and pre NDI score of (4.81±1.2116.73±3.27). All two groups were matched in term of age, BMI, duration in week, VAS, NDI. The baseline characteristics were equivalent across the intervention groups (p>0.05). Age Distribution Table:2 MEAN AGE DISTRIBUTION OF CHRONIC NON SPECIFIC NECK PAIN MEAN AGE GROUP N SD (IN YEARS) GROUP A 32 21.65 10.82 GROUP B 32 26.43 13.21 TOTAL 64 24.04 12.02 The table displays the statistics of age distribution among 61 chronic non specific neck pain patients INTRA GROUP COMPARISION OF TWO OUTCOME MEASURES Paired t-test was used to compare the Pre-intervention values of outcome measure i.e. VAS and NDI with and post intervention values with the groups. Table:3 Intra-Group comparison of mean of VAS, and NDI score before and after 4 weeks intervention using paired t test. GROUP A (GPR) GROUP B (NDI) VARIABLE Pre - Post - P-Value Pre - Post - P-Value Intervention Intervention Intervention Intervention Mean ± SD Mean ± SD Mean ± SD Mean ± SD VAS 4.53±1.15 0.65±0.63 0.000 4.81±1.21 1.29±0.50 0.000 NDI 15.41±3.43 1.54±2.06 0.000 16.7±3.27 3.66±2.24 0.000 Table shows GROUP A Mean of Pre VAS (4.53±1.15) and Post VAS (0.65±0.63) p<0.05 and Mean of Pre NDI (15.41±3.43) and Post NDI (1.54±2.06) p<0.05..In GROUP B Pre VAS (4.81±1.21) and Post VAS (1.29±0.50) p<0.05 and Mean of Pre NDI (16.7±3.27) and Post NDI (3.66±2.24) p<0.05 .There is significant difference between pre and post VAS and NDI in GPR and SS group. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 451 INTER GROUP COMPARISION OF OUTCOME MEASURE Table:4 Inter group comparison of mean difference value of VAS and NDI of two groups using independent t test. GROUP A (GPR) GROUP B (SS) VARIABLE Post-Pre Diff Post-Pre Diff P VALUE (Mean ± SD) (Mean ±SD) VAS -3.96 ±1.0 -3.52±1.0 0.93 NDI -13.87±3.10 -13.06±2.49 0.27 A comparison of the mean difference of VAS and Each stretching modality has specific features. Global NDI between two groups was done using independent or muscle chain stretching is active and requires the t-test. It was carried out to analyze is there any significance patient’s perception and concentration under a trained between two groups and to find out the effective to therapist’s supervision, whereas conventional stretching improve the pain and disability in chronic non-specific is simpler and may be passive or auto-passive and easily neck pain patients. For VAS Mean difference of GPR learned. Nonetheless, the two stretching programs is (-3.96±1.0), (-3.52±3.1) and p>0.05. For NDI Mean produced equivalent results.10 difference of SS is (-13.87±3.10), (-13.06±2.49 and It might be argued that the stretching time is different p>0.05. No significant differences were observed in both programs; however, the total stretching time between the groups for both outcome measures. was equal in both groups, and there are no studies that Discussion suggest that a longer duration (15 minutes) of stretching is more effective than a shorter one (30 seconds).10 The present results indicate that both GPR and static stretching, in association with conventional therapy The balance between groups may also be explained were effective in reducing pain and improving disability by the fact that, while in GPR, the stretch force is slowly in patients with chronic non specific neck pain, with no and gradually distributed along the muscles that make significant differences between groups.10 up the muscle chain, while in static stretching, the force is more intense but focused and for a shorter period of In the present study, the choice of associating time. In both cases, the same process, that is, visco- stretching to pompage was due to the latter being a safer elastic stress relaxation17 takes place, and muscles are form of manual therapy compared to joint manipulation, maintained in a static elongated position, regardless of wherein adverse effects are rarely seen. According to the type of stretching. Bronfort et al, 12 frequent adverse effects include pain worsening, discomfort, dizziness, visual disturbance, Furthermore, the similarity of observed results and ear symptoms. may be due to the fact that both stretching regimes were performed under the supervision of the same 13 12 According to Wang et al, Bronfort et al, and therapist, with the same care and according to the same 14 Evans et al, patients who performed exercises and had principles: keeping a regular breathing rhythm with no manual therapy exhibited higher levels of satisfaction inspiratory block, never provoking pain, and avoiding and performance when compared to patients who only compensations; that is, while a muscle segment is being received manual therapy. stretched, the compensating shortening of other distant 10 Our results did not show differences between muscles is not allowed. groups, that is, between the two kinds of stretching. 452 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 This explanation might also account for the similar Conclusion results obtained by Rosário et al15, Cabral et al72 and Global postural Re-education and Static stretching, Maluf18 who also compared the two kinds of stretching in association to conventional therapy, were equally and found them to be equally effective. effective in reducing pain and disability in women with Our results are similar to those by Cunha et al, chronic non specific neck pain. who found no significant differences on pain, range of Conflict of Interest: None. motion and quality of life comparing conventional static stretching and GPR in patients with chronic neck pain. Source of Funding: Self. However, these results are different from those by, Ethical Clearance: The ethical clearance was Francesca Bonetti who found significant difference in obtained from the Institutional ethical committee South ooutcomes comparing GPR and stabilization exercise in Gujarat medical education and research center SPB chronic low back pain. The reasons for these differences physiotherapy college under VNSGU. may be related both to the areas affected by spinal pain, and to the fact that GPR might be more effective References when compared to analytical stabilization, although not 1. Cote Pierre, J. David Cassidy and Linda Carroll. superior to other stretching techniques. The Saskatchewan Health and Back Pain Survey: The Prevalence of Neck Pain and Related Disability A literature review4 concluded that the GPR method in Saskatchewan Adults. Spine1998; 23(15): 1689- has been shown to be an effective treatment technique 1698. for musculoskeletal diseases. One more study comparing 2. Guzman J, Haldeman S, Carroll LJ, et al; Bone muscle chain and conventional stretching16 with results and Joint Decade 2000–2010 Task Force on Neck that favor GPR was found in literature. Unfortunately, Pain and Its Associated Disorders. Clinical practice those findings cannot be compared to the results obtained implications of the Bone and Joint Decade 2000– in this study since patients in that study had ankylosing 2010 spondilytis. 3. Task Force on Neck Pain and Its Associated Global postural re-education may be a gentle option Disorders: from concepts and findings to to propose movement without pain, enhance relaxation recommendations. Spine (Phila Pa 1976). 2008; 33 via respiratory rhythm, and offer a positive experience (4 suppl):S199 –S213. of body posture modification. This approach to a clinical 4. Häkkinen A, Salo P, Tarvainen U, et al. Effect encounter can influence not only the “posture” but also of manual therapy and stretching on neck muscle the negative feelings and beliefs that are frequently strength and mobility in chronic neck pain. J Rehabil Med. 2007; 39: 575–579 associated with chronic pain.11 5. Teasell RW, Shapiro AP & Mailis A (1993) This study has limitations, such as we included Medical management of whiplash injuries. Spine: only female patients, an absence of a control group, State of theArt Reviews 7: 481–499 and the short follow-up period. Patients were also told 6. Vanti C, Generali A, Ferrari S, et al. General not to change their usual medications, which may have postural rehabilitation in musculoskeletal diseases: helped in reducing pain. At the end of treatment, 90% scientific evidence and clinical indications [in of subjects reported a reduction in medication usage. 10 Italian]. Reumatismo. 2007; 59: 192–201. 7. Bonetti F, Curti S, Mattioli S, et al. Effectiveness The results of this study are easily generalizable of a “Global Postural Reeducation” program in common clinical practice due to the inexpensive for persistent low back pain: a non-randomized interventions, equipment, and setting involved. controlled trial. BMC sculoskelet Disord. 2010; 11: Moreover, the characteristics of the participants are 285. similar to those of individuals who are normally seen for 8. Kisner C, Colby LA. Exercícios terapêuticos - physical therapy management of NP.11 fundamentos e técnicas. São Paulo: Manole; 1992 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 453 9. Marques AP .Cadeias muculares;um programa para Phys Med Rehabil. 2003; 82: 203-18. ensinar avaliacao fiioterapeutica global.Sao Paulo: 14. Evans R, Bronfort G, Nelson B, Goldsmith CH. Manole:2005 Two-year follow-up of a randomized clinical trial 10. Ana Claudia violin cunha1,thomaz nogueria of spinal manipulation and two types of exercise for burke11,Fabio Jorge renovato franca11Amelia patients with chronic neck pain. Spine. 2002; 27: Pasqual Marques11effect Of Global Posture 2383-9. Reeducation And Of Static Stretching On Pain 15. Rosário JLP, Sousa A, Cabral CMN, João SMA, ,Range Of Motion,And Quality Of Life In Women Marques AP. Reeducação postural global e With Chronic Neck Pain:A Randomized Clinical alongamento estático segmentar na melhora da Trial. Clinics2008;68(6):763-70 flexibilidade, força muscular e 11. P. Pillastrini, F. de Lima e Sa´ Resende, PT, PhD, 16. Fernández-de-las-Peñas C, Alonso-Blanco C, Effectiveness of Global Postural Re-education Morales-Cabezas M, Miangolarra-Page JC. Two in Patients With Chronic Nonspecific Neck Pain: exercise interventions for the management of Randomized Controlled Trial patients with ankylosing spondylitis. Am J Phys 12. Bronfort G, Evans R, Nelson B, Aker PD, Med Rehabil. 2005;84:407-19 Goldsmith CH, Vernon H. A randomized clinical 17. McHugh MP, Magnusson SP, Gleim GW, Nicholas trial of exercise and spinal manipulation for patients JA. Viscoelastic stress relaxation in human skeletal with chronic neck pain. Spine. 2001; 26:788-99. muscle. Med Sci Sports Exerc. 1992;24:1375-82. 13. Wang WTJ, Olson SL, Campbell AH, Hanten WP, 18. Maluf SA. Efeito da reeducação postural globale Gleeson PB. Effectiveness of physical therapy for do alongamento estático analítico em portadores patients with neck pain: an individual approach de disfunção temporomandibular: um estudo using a clinical decision-making algorithm. Am J comparativo [Tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2007 454 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13888 Comparison on Perception and Attitude of Patients Seeking Private College and Private Clinic In Chennai City – A Cross Sectional Study Suba.A 1, Lubna Fathima2, Sunayana Manipal3, Prabu. D4, Raj Mohan5, Bharathwaj6 1Under Graduate Student (Bachelor of Dental Surgery), 2Post Graduate Student (Master of Dental Surgery), 3Master of Dental Surgery, Senior lecturer, 4Master of Dental Surgery, 4Master of Dental Surgery, Reader, 5Master of Dental Surgery, Professor and Head, Department of Public Health Dentistry, SRM Dental College and Hospital, Ramapuram, Chennai, India Abstract Background: Attitude and perception goes hand in hand. Since supportive review of literature were not available. This study is an attempt to assess the attitude level of bioethics among the private college and private clinic patients in chennai city. Aim: This study aims to assess the attitude level of bioethics among the private college and private clinic patients in chennai city Materials And Method: Two hundred individuals participated in the study .A set of 100 questions were given to the private college patients and a set of 100 questions were given to private clinic patients and the answers obtained was tabulated and recorded. Statistical Analysis: Descriptive statistics were calculated for all the questions recorded among the private college patients and private clinic patients and chi square test was done to find the association between the questions recorded. Result: Total of 200 Individual participants signed the consent form. Nearly a higher percentage of individuals told that economically college base set up was best and when assessing the appointment schedule private clinic were having a significant result. Chi square test was performed to find association between the questionnaire given in private clinic and private hospital. Conclusion: Using the survey which consisted of questionnaire on the attitude among private college patients and private clinic patients in chennai city the results and conclusions are discussed in the presentation. Keywords: Attitude, perception, private college and private clinic Introduction sails. Here it begins the attitude. Attitude and perception goes hand in hand. The total number of private dental The pessimist complains about the wind; the college in chennai city are 13.The total number of optimist expects it to change; the realist adjusts the dentist registered in Tamil Nadu are 13,286 and where studying was conducted and found that there 1,280 private dental clinic in Chennai.[1] Salinas H et al has Corresponding Author: Dr. Lubna Fathima mentioned about the amount of more patients flow delt Designation: Post Graduate Student (Master of Dental with private college are due to the cost effective rather Surgery), Department of Public Health Dentistry. than private clinic The ambience was well in private a Address: SRM Dental College and Hospital, Bharathi college compared to private clinic due to count of chairs Salai, Ramapuram, Chennai, Tamilnadu-600089. and equipments(2).Satheesh et al has discussed about the Email: [email protected] sterilization and has discussed that went it comes to more Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 455 patients the sterilization of instruments is quite lesser to participate in the study. This study was conducted when compared to private clinic because in clinic each using questionnaire to assess the knowledge, attitude individuals is taken care personally due to lesser number and practices among the patients seeking private college of patients .The quality of treatment is better in private and private hospital. The questionnaire were designed clinic due to experienced doctors and advancement of according to the following sections, equipments and instruments serves good in private clinic • A) knowledge (3)Brahmbhatt et al has explained that when it comes to emergency Private college has the best because it has • B) Quality of treatment attached with general hospital with first aid kit facilities but in private clinic the facilities for emergency kit is not • C) Appointment much available(4).Due to appointments private college • D) Sterilization of instrument has more advantage because the number of doctors and students are more in number so many patients • E) Distance can be treated compared to private clinic .Attitude is a psychological construct, a mental and emotional entity • F) Economical (5) that inheres in, or characterizes a person .they are In this study two hundred individuals participated in complex and acquired state through experiences. It is an which a set of hundred questions were given to private individual predisposed state of mind regarding a value college patients and a set of hundred questions were and it is precipitated through a responsive expression given to private clinic patients. A total 200 patients towards a person, place, thing, or event which in turn responded the survey form. influences the individuals thought and action (6) .Change in attitude can lead the individuals to knook and corner Statistical Analysis: Descriptive statistic were of the world (7), So to assess the attitude level of bioethics calculated for all the questions recorded among the among the private college patients rather than private private college and private clinic patients and chi clinic patients in chennai city. square test was done to find the association between the questions recorded Materials and Method Results The present study was a cross sectional study received conducted among the patient seeking private The present study was conducted on 100 individuals college and dental clinic to assess their knowledge, of private college patients and 100 individuals of private attitude and practice towards seeking the private college clinic patients in Chennai city. Out of 200 individuals, and dental clinic in chennai city. Ethical clearance and 200 individuals were filled the questionnaire .In this approval obtained from the institutional review board. study the attitude of private college patients was 45% The period of recruitment and data collection was males and 55% females and the private college patients between in the month of September 2019. Convenience was 37%males and 63%females. The set of 10 questions sampling was used and patients visited the private which were recorded to analyze the knowledge of the college and private clinic at the time of study were patient seeking private college and private clinic and included. All individuals willing to participate in the association between the questions were found to be study were included. Exclusion criteria included who statistically significant with the p value of <0.005. were not ready to answer the questions and not willing 456 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Table 1: Knowledge among the patient seeking private college and private clinic Yes No Question P value (%) (%) Have you visited a dental clinic 92 8 0.001 Have you visited a dental college 71 29 0.002 Are you content (or) comfortable with the treatment provided in dental college 37 63 0.001 Do you think that the treatment provided in dental college is better..? 71 29 0.000 Do you think there will be more than one experienced professionals to suggest 31 69 0.002 the best treatment in dental clinic Do you like the infrastructure in dental college 73 27 0.001 Do you like the facilities provided in dental clinic 57 43 0.004 Table 2: Economical opinion among the patient seeking private college and private clinic Question Yes No P value Do you think that the cost for the treatment is economical in dental college..? 96% 4% 0.5016 Table 3: Quality of the treatment among the patient seeking private college and private clinic Question Yes No P value Do you think college provided better quality treatment 56% 44% 0.000 Which among the following do you expect from dental college 17 63 0.010 Table 4: Distance related attitude among the patient seeking private college and private clinic Question Yes No P value Do you think the distance of college is nearer 16% 84% 0.018 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 457 Table 5: Appointment related attitude among the patient seeking private college and private clinic Question Yes No P value Do you think better appointments are given in private hospital 26% 74% 0.008 Table 6: sterilization related attitude among the patient seeking private college and private clinic Question Yes No P value Do you think the cleanliness of instruments is better in dental college 16% 84% 0.011 Discussion where although autoclave was identified as the most The result of the cross Sectional study was to common method of sterilization by most respondents, assess the attitude of private college patient rather than it was seen the many of the autoclave were modified seeking in private clinic found that while asked about pressure cookers. Regarding quality of treatment A.P. 8 appointments scheduling, 55% preferred private college Griffin and J. L. LEWIS Jr et al,. , discussed about the and 45% preferred private clinic. When we asked about primary responsibility of any dentist is to provide quality the cleanliness of instruments, 42% of patients agreed oral and dental health care to the patient .The dental that private college was better and 58% patients agreed practitioner thus should maintain a balance between that private clinic is better. When we asked about more patient care and business requirements while keeping than one experienced professionals would suggest the moral, ethical, legal and professional responsibilities 9 treatment plan in dental college 65%were agreed that in proper perspective . Regarding economical metsky, private college had more experienced professionals Cooperman has discussed Even in a highly successful and 35% were agreed that private clinic had more than practice with a good cash flow; things can go haywire one experienced doctor. When we asked about the one has to watch out for patients paying 2-3 months 10,11 infrastructure in private college 57% were agreed that late . One has to work with an accountant regarding infrastructure was better in private college than private the cash collection policy both during the boom time clinic. When we asked about the cost is economically and during the lull phase of practice .patients should be 12,13 reasonable in private college 100% patients agreed that asked to make payments upfront . This ensures that private college was economical than the private clinic. they do not miss their scheduled appointment. .The association between the questions answered by Conclusion patient visiting private clinic and patients visiting private hospital is was found that the p-value was found to be The above study concludes that cost of the treatment statistically significant i.e. <0.005.When the patients and expert professionals are ahead superior in private were questioned about the convenience of the treatment college went compared to private clinic. Whereas, provided in dental college 37% answered than dental quality of the treatment and sterilization is better in college was convenient and 63% patients answered that private clinic went compared to private college. private clinic was convenient. When the patients were Ethical Clearance: Ethical clearance was taken asked if they had visited a private clinic setup 51% from the institutional review board. patient had visited the private college set up. When the patients were questioned about the distance they had to Conflict of Interest: Nil travel to college 63% patient suggest that college was far than the private. Regarding sterilization puttaiah et Source of Funding: self funding al 2010 in Tamilnadu and Karnataka states of India, 458 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Reference implementation 1. Salinas H, Erazo M, PAstén J, Preisler J, Ide 8. Nazir MA, Izhar F, Tariq K, Anjum KM, Sohail R, Carmona S, et al. Indicadores de calidad de ZB, Almas K. A cross-sectional study of dentists asistenciaobstétrica. Rev ChilObstetGinecol. about the need for a practice management course in 2006;71(2):11420 undergraduate dental program. European journal of dentistry. 2018 Oct;12(4):508 2. Satheesh BC, Prithviraj R, Prakasam PS. A study of perceived stress among undergraduate medical 9. A cross-sectional study of dentists about the need students of a private medical college in Tamil for a practice management course in undergraduate Nadu. Int J Sci Res 2015;4:994-7. dental program. Nazir MA, Izhar F, Tariq K, Anjum KM, Sohail ZB, Almas K. Eur J Dent. 2018 Oct- 3. Brahmbhatt KR, Nadeera VP, Prasanna KS, Dec;12(4):508-515. doi: 10.4103/ejd.ejd 184 18.: Jayram S. Perceived stress and sources of stress among medical undergraduates in a private medical 10. Oberoi SS, Sharma N, Mohanty V, Marya C, college in Mangalore, India. Int J Biomed Adv Res Rekhi A, Oberoi A, et al. Knowledge and attitude 2013;4 of faculty members working in dental institutions towards the dental treatment of patients with HIV/ 4. Sleep J, Grant A, Garcia JO, Elbourne D, Spender J, AIDS. IntSch Res Notices 2014;2014:429692. Chalmers I. West Berkshire perineal management trial 11. S. Kohli, S. Bhatia, A. Kaur, and T. Rathakrishnan, “Patients awareness and attitude towards dental 5. 5.R.L. Glass (Ed.), The First international implants,” Indian Journal of Dentistry, vol. 6, no. 4, conference on declining prevalence of dental caries: pp. 167–171, 2015. the evidence and impact on dental education, dental research and dental practice, J Dent Res, 61 (1982), 12. Gerbert B, Badner V, Maguire B, Martinoff J, pp. 1301-1383 Wycoff S, Crawford W, et al. Recent graduates’ evaluation of their dental school education. J Dent 6. 6.Dhanya RS, Hegde V, Anila S, Sam G, Khajuria Educ. 1987;51:697–700. RR, Singh R, et al. Knowledge, attitude, and practice towards HIV patients among dentists. J 13. Pousson RG, McDonald GT. A model for increasing IntSocPrev Community Dent 2017;7:148-53. senior dental student production using private practice principles. J Dent Educ. 2004;68:1272–7. 7. 7.Safi Y, Khami MR, Razeghi S, Shamloo N, Soroush M, Akhgari E, et al. Designing and DOI Number: 10.37506/ijphrd.v12i1.13890 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 459 The Usefulness of Computer Assistive Technology for Persons with Visual Impairment Sulagodu Prakash Bhavna1, Beula Christy2, Sania Sulthana3, Prasanna Reddy4 1M Optom, FASCO, Sankara Eye Hospital, Bangalore, 2PhD L V Prasad Eye Institute, Hyderabad, 3B Optom, Ramalayam Street, Srinagar Colony, Wanaparthy district, Telangana, India, Yadaki, 4B OptomTadipatri, Anatapur, Andhra Pradesh, India Abstract Purpose State: To evaluate the usefulness of computer assistive software technology by persons with visual impairment in their education, employment, communication, and leisure activities. Methods: Hundred and sixteen individuals with visual impairment were recruited from the rehabilitation center of LV Prasad Eye Institute, Hyderabad. The mean age of the study participants was 24.99 years (range 16 to 48, median 42 years), and 81(69.8%) were male. QUEST (2.0) was administered to measure outcomes. Data collected were analyzed with SPSS software. Results: JAWS is the most preferred and used software 110(94.8%). Computer usage was indicated for more than 7 hours per week by more than half of the participants 55(56.0%). The usefulness of assistive software was reported for education 114(98%), communication 112(96.5%), job 52(44.82%), and leisure activities 101(87.06%). Proficiency in accessing computer applications with Assistive Technology was appreciated in programs such as MSWord 10(8.6) to 64(55.2) MS – Excel 16(13.8) to 57(49.1), MS- Powerpoint 30(25.9) to 43(37.1), Internet 19(16.4) to 54(46.6), Social websites 20(17.2) to 25(21.6) and Accountancy 5(4.3) to 3(2.6). The overall QUEST mean score of 4.67 with 4.5 on device subscale and 4.8 on service subscale demonstrated participants’ satisfaction on assistive software. Discussion: Assistive software technology can support persons having visual impairment, with gainful employment, social inclusion, and confidence in the community. Implications for practitioners: Assistive software technology would be very helpful to the persons with visual impairment if they are taught and put into practise pro-actively by eye care providers. Keywords: Visual impairment, Assistive technology, Usefulness, QUEST. Introduction The user’s satisfaction determines the effectiveness of an AT to the degree to which a desired or planned Technology promotes the acquisition of literacy, improvement is accomplished in their natural provides access to information required for employment, environment 4. Two critical factors influence the users’ education, and facilitates social and community satisfaction; the convenience of handling the ‘device/ networks.1. technology’ and the ‘service/learning experience’ Assistive Technology (AT) is used as a means so provided by the professionals to its usage. There are that people with disabilities can perform the tasks they few studies on outcome measures by standardized want to accomplish 2. Assistive Technology has created assessment tools PIADS 5 and QUEST 6. However, its many positive opportunities for people with disabilities usage is limited to the measurement of assistive devices related to employment, education, communication, for mobility-impaired and physically impaired. No independent living, and leisure 3. previous research, yet, could be identified that measured 460 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 outcomes on users’ satisfaction on computer assistive people who use assistive technology in South Korea.10 technology. . Desideri L, Stefanelli B, et al., (2014), the authors of this paper have conducted a study on parents’ experience The purpose of our study is to evaluate the in assistive technology service delivery. The tools used usefulness of assistive software technology by persons were KWAZO and QUEST 2.0. 11. with visual impairment in their education, employment, communication, and leisure activities. Methods and Materials Review of Literature Our prospective study included persons with visual impairment who had undergone computer assistive Assistive technologies, such as screen readers, software technology training. The training session was and digital image enhancements, breaks the challenge held between November 2011 and June 2014 at Dr. of accessing computers easier by persons with visual PRK Prasad center for rehabilitation of the Visually impairment. 7 It can help both to enhance and to Impaired and Blind in L V Prasad Eye Institute, a center substitute for the visual and sensory functions that are of excellence in Hyderabad, Telangana state, India. required during computer use. One hundred and sixteen persons with visual Assistive technologies allow users to become impairment out of the total One sixty-three, who independent, experience greater feelings of security, completed computer assistive software technology social integration, enhance autonomy, and have higher training at Dr. PRK Prasad Centre for Rehabilitation socio-economic aspirations. Technology has empowered of Visually Impaired and Blind, were recruited in our visually impaired access to the science of computers and study. its applications through a range of assistive software. Some of them are JAWS (Job Access with Speech), We included persons aged 16 years or older, who Kurzweil, NVDA (Non-Visual Desktop Access), were willing to participate in the study. The overall period Windows eye, Dolphin supernova, ABBYY fine reader, taken to complete the administration of questionnaires MAGic, ChromeVox, and Voice over by visually for the trial for 116 subjects was three months (January impaired. In our study, we assessed the satisfaction of 2015 to March 2015). The institutional review board the study participants using QUEST 2.0 questionnaire as approved of our study design and protocol (IRB LEC we felt the same to be very apt for our research. 12-14-144), and the research adhered to the tenets of the declaration at Helsinki. Informed consent was obtained Outcome measures of assistive technology from before the administration of the questionnaire. previous studies Study questionnaire: A systematic review of 108 published articles by Jeffrey W, Graham Strong et al. (2009) has studied A general survey related to the participant’s use and the effectiveness of assistive devices used by persons experiences of computer and assistive technology was with visual impairment. They used the ‘downs and assessed. black’ checklist for randomized control trials and 1. Part I – General Information including nonrandomized studies. The study conducted by Jutai demographics and medical details et al. concluded the need for more research related to performance, measurement, and the effectiveness of 2. Part II – Self-reported benefits of computer- 8 vision rehabilitation devices. . William Paul (1999), based assistive technology has narrated his experience with assistive technology. He had shared his struggles to explore this technology 3. Section III – Self-reported proficiency in with numerous discussions with equipment developers, computer usage through assistive software manufacturers, and support service providers for the 4. Part IV – Level of computer usage post-training users. 9. Sang Heon Lee (2014), the author of this article, conducted a study to know the user satisfaction of 5. Part V – QUEST 2.0 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 461 The QUEST (Quebec User Evaluation of Satisfaction The usefulness of assistive software in daily life with Assistive Technology) questionnaire, which is was perceived well in all areas such as education, based on the Likert scale wherein 1 is not satisfied at all communication, proper uses, and leisure activities. and five, is very satisfied. (Table 2). The proficiency in accessing different computer applications by the majority of the participants Results: was excellent in almost all programs accessing social Hundred and sixteen individuals with visual websites and accounting (Table 3). Usage of computer impairment were recruited for the study. The mean age post assistive technology training, it was seen that sixty- of our participants was 24.99 years (range 16 to 48, five people (56.0%) among the 116 use the computer for median 42 years). Ninety participants (77.6%) had a more than 7 hours weekly. (Table 4). severe visual impairment (best-corrected distance visual In the item by item analysis of the QUEST score acuity of <6/60 to NPL), and 96(82.8%) had visual on users’ satisfaction with assistive software and service field loss (less than 10 degrees) (Table 1). JAWS is the provider, the total mean of device subscale score (4.5) most preferred and used software 110(94.8%) among and service subscale (4.8) and overall mean score (4.67), low vision, severe low vision and persons with visual indicates that the participants were “quite satisfied” with impairment. Half of the participants indicated their the usefulness of assistive computer software as well as average computer usage as more than seven hours per with the training instructors. (Table 5, 6) week (56.0%). Table 1 Table showing the demographic and medical details TOPIC FREEQUENCY Age 24.99(mean) Gender Male 81(69.8%) Education I to x 5(4.3%) XI to XII 20(17.2%) Under Graduate 60(51.7%) Post Graduate and above 31(26.7%) Occupation Unemployed 46(39.7%) Employed 42(36.2%) Student 28(24.1%) Diagnosis Globe related 20(17.2%) Lens related 4(3.4%) 462 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Cont... Table showing the demographic and medical details Cornea related 5(4.3%) Glaucoma 9(7.8%) Retina related 65(56.0%) Others 13(11.2%) BCVA (distance) 6/18 to 6/60 26(22.4%) >6/60 to NPL 90(77.6%) Table 2 Table showing the usefulness of assistive software in day-to-day activities Unsatisfactory n Total (n=116) Fair Good Very Good Excellent Not applicable (%) Educational 0(0.00) 3(2.6) 19(16.4) 31(26.7) 61(52.6) 2(1.7) purpose(n=114) Communication 0(0.00) 0(0.00) 17(14.7) 32(27.6) 63(54.3) 4(3.4) purpose(n=112) Job related 0(0.00) 3(2.6) 5(4.3) 14(12.1) 30(25.9) 64(55.2) purpose(n=52) Leisure 0(0.00) 5(4.3) 27(23.3) 25(21.6) 44(37.9) 15(12.9) activities(n=101) Table 3 Table showing proficiency in using assistive technology Unsatisfactory Program Fair Good Very good Excellent Not applicable n (%) Note pad 0(0.00) 4(3.4) 25(21.6) 42(36.2) 44(37.9) 1(0.9) Microsoft word 0(0.00) 1(0.9) 10(8.6) 39(33.6) 64(55.2) 2(1.7) Microsoft excel 0(0.00) 2(1.7) 16(13.8) 36(31.0) 57(49.1) 5(4.3) Microsoft PPT 1(0.9) 3(2.9) 30(25.9) 29(25.0) 43(37.1) 10(8.6) Internet 0(0.00) 7(6.0) 19(16.4) 29(25.0) 54(46.6) 7(6.0) Social websites 1(0.9) 7(6.0) 20(17.2) 19(16.4) 25(21.6) 44(37.9) Accountancy 2(1.7) 4(3.4) 5(4.3) 2(1.7) 3(2.6) 100(86.2) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 463 Table 4 Table showing frequency of computer usage Hours per week Frequency n (%) 0 hours per week 11(9.5%) 1 to 2 hours per week 12(10.3%) 2 to 5 hours per week 17(14.7%) 5 to 7 hours per week 11(9.5%) More than 7 hours per week 65(56.0%) Table 5 Table showing QUEST user satisfaction of device Not satisfied at Not very More or less Quiet satisfied Very satisfied all n (%) satisfied satisfied Adjustment 0(0.00) 1(0.9) 9(7.8) 31(26.7) 75(64.7) Ease 0(0.00) 1(0.9) 8(6.9) 25(21.6) 82(70.7) Comfort 0(0.00) 1(0.9) 8(6.9) 24(20.7) 83(71.6) Effectiveness 0(0.00) 2(1.7) 7(6.0) 19(16.4) 88(75.9) QUEST: Quebec User Evaluation for Satisfaction of Assistive Technology Table 6 Table showing QUEST user satisfaction on service provided Not satisfied at all More or less Not very satisfied Quite satisfied Very satisfied n (%) satisfied Service delivery 0(0.00) 1(0.9) 4(3.4) 28(24.1) 83(71.6) Professional 0(0.00) 0(0.00) 0(0.00) 11(9.5) 105(90.5) services Follow-up services 0(0.00) 0(0.00) 2(1.7) 15(12.9) 99(85.3) QUEST: Quebec User Evaluation for Satisfaction of Assistive Technology 464 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Discussion school curriculum itself as it is for the sighted students. The addition of assistive technology to the school This study aimed to assess the experiences and curriculum could go a long way in aiding the visually satisfaction level of computer assistive technology impaired. Assistive technology can also be a stepping by the visually impaired. The overall results of the stone to visually challenged people to achieve their survey indicate that computer assistive technology is aspirations in life. perceived as an essential tool in achieving educational, employment, and personal goals by the users. Ethical Clearance: The institutional review board approved of our study design and protocol (IRB LEC In terms of utilization of software 65(56%), nearly 12-14-144), L V Prasad Eye Institute. two-thirds of the participants expressed that they are accessing computers for an average of more than 7 Source of Funding: Self hours per week. Equal educational opportunities of the blind through assistive technology is emphasized in Conflict of Interest: Nil the ‘Persons with Disabilities Act’ 12 emphasis. This References result indicates the positive trend of a rapid increase in accessing the computer by the blind, thus anticipated 1. DVI Position Paper on Assistive Tech (4). educational achievements. The social inclusion of 2. Hoppestad BS. Essential elements for assessment visually impaired in regular mainstream is exceptionally of persons with severe neurological impairments positive that access to assistive software by the blind is for computer access utilizing assistive technology becoming an integral part of the work environment. devices: a Delphi study. Disabil Rehabil Assist Technol. 1(1-2):3-16. http://www.ncbi.nlm.nih. Job Access with Speech (JAWS) software is the gov/pubmed/19256163. Accessed October 2, 2019. most preferred assistive computer software used by 3. Blanck P, Ritchie H, Schmeling J, Klein D. 110(94.8%) of participants. The user’s satisfaction on Technology for Independence: A Community- any assistive device is judged by its ease, adjustment, Based Resource Center. Behav Sci Law. comfort, and effectiveness. The overall QUEST device 2003;21(1):51-62. doi:10.1002/bsl.522 score ‘4’ measured is evident for the sophistication of 4. Jutai JW, Fuhrer MJ, Demers L, Scherer MJ, the software JAWS used by the participants. DeRuyter F. Toward a taxonomy of assistive technology device outcomes. Am J Phys Med The success or failure of any assistive device is highly Rehabil. 2005;84(4):294-302. doi:10.1097/01. influenced by the ‘service providers.’ Each visually phm.0000157313.88732.dc impaired is unique; hence it might require different 5. Demers L, Monette M, Descent M, Jutai J, Wolfson instructional strategies to adapt to learning. Therefore C. The Psychosocial Impact of Assistive Devices the role of the service provider plays an essential role in Scale (PIADS): translation and preliminary giving a good learning experience to the user. Positive psychometric evaluation of a Canadian-French feedback on the ‘service provider’ subscale from nearly version. Qual Life Res. 2002;11(6):583-592. 100% of the participants (service delivery, professionals http://www.ncbi.nlm.nih.gov/pubmed/12206579. support, and follow-up support) is the evidence for the Accessed September 30, 2019. quality and committed services provided by the team 6. Wessels RD, De Witte LP. Reliability and validity where the current study is conducted. of the Dutch version of QUEST 2.0 with users of various types of assistive devices. Disabil Rehabil. Conclusion 2003;25(6):267-272. http://www.ncbi.nlm.nih.gov/ In conclusion, almost all the visually impaired pubmed/12623616. Accessed October 2, 2019. persons in our study thought that computer assistive 7. Leat SJ, Omoruyi G, Kennedy A, Jernigan technology is essential for social inclusion and gainful E. Generic and customized digital image employment. Training in assistive computer software enhancement filters for the visually impaired. technology should be a fundamental component in the Vision Res. 2005;45(15):1991-2007. doi:10.1016/j. visres.2005.01.028 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 465 8. Jutai JW, Strong JG, Russell-Minda E. 11. Desideri L, Stefanelli B, Bitelli C, Roentgen U, Effectiveness of Assistive Technologies for Low Gelderblom G-J, de Witte L. Satisfaction of users Vision Rehabilitation: A Systematic Review. with assistive technology service delivery: An J Vis Impair Blind. 2009;103(4):210-222. exploratory analysis of experiences of parents of doi:10.1177/0145482X0910300404 children with physical and multiple disabilities. 9. Paul W. The role of computer assistive technology Dev Neurorehabil. 2016;19(4):255-266. doi:10.31 in rehabilitation of the visually impaired: a personal 09/17518423.2014.988303 perspective. Am J Ophthalmol. 1999;127(1):75-76. 12. Ministry of Law Justice and Company Affairs. The doi:10.1016/s0002-9394(98)00390-0 Persons with Disabilities ( Equal Opportunities , 10. Lee SH. Users’ satisfaction with assistive devices Protection of Rights and Full Participation ) Act , in South Korea. J Phys Ther Sci. 2014;26(4):509- 1995. 1995;1995(10):1-20. http://socialjustice.nic. 512. doi:10.1589/jpts.26.509 in/pwdact1995.php. 466 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13893 Evaluation of Maternal Health Services at Session Site During Health and Nutrition Day in Urban Slums of Western Odisha Sushree Priyadarsini Satapathy1, Bharati Panda2, Jasmin Nilima Panda3, Sadhu Charan Panda4 1 Senior Resident, 2Assistant Professor,3 1st year PG student,4Professor & HOD, Department of Community Medicine, VIMSAR,Burla Abstract Background :UHND would serve as a common platform to deliver maternaland nutrition services to the urban poor population. This study was formulated with the Objectives :1) To assess the availability of resources for providing maternal health services in the study area. 2) To determine the utilisation pattern among the beneficiaries at session sites.3) To study the association of socio-demographic characteristic’s of the beneficiaries with the utilisation of services by them.Material & Methodology : A cross-sectional study carried out in the UHND sessions being conducted under UHTC of Burla for a period of 3months i.e August- October 2019.25 UHND session sites were taken for input and process evaluation & 4 pregnant women from each session i.e total of 100 were included for outcome evaluation.Data collected by semi-structured, pre-tested checklist which includes questionnaire’s regarding the presence of service providers at the session site, availability of required equipment’s and the direct observation of service provision at the site and the benefits of the services availed by the beneficiaries.Results:Out of 25 UHND session being conducted under UHTC, Burla it was found out that 24 i.e (96%) of session sites were conducted as per micro-plan.Display of IEC banner was at 80% of session sites.Fetoscope was not available at all the session sites while measuring tape and gloves were available at 56% and 68% of session sites.Abdominal examination &FHS auscultation was not done in any session site due to absence of Privacy &fetoscope.In our study it was found that service utilisation is inadequate among 48% of the beneficiaries.Conclusion:Satisfactory maternal services were provided in many session sites, but still there is some lacuna in the services. Effective training and retraining of all health workers at regular interval is required for morebetter outcome. Keywords : UHND, urban slums, maternal health services, AWC,U-ASHA. Introduction the much needed behavioural changes in the community and improving the health-seeking behaviour of the Anganwadi Centres (AWC) acts as a strong community, leading to better health outcomes in the platform for maternal and child health services along rural areas. 1 with promoting effective inter-sectorial convergence. The Village Health and Nutrition Day (VHND) acts However, in urban areas, there was no such as an interface between the community and the health mechanism in place to look after the health needs of the system. Ithas contributed significantly in bringing about urban poor especially those who live in urban slums or slum like conditions. As per Census 2011, the urban population has reached Corresponding Authour: 37.7 crores which is 31.16% of the total population, Dr.Bharati Panda compared to 28.6 crores people as per Census 2001. 2 Assistant Professor, Department of Community According to expert group planning commission- 2009, Medicine, VIMSAR, Burla Odisha is having the 2nd highest rates of urban poverty Email: [email protected] i.e(37.6%) after Bihar (43.7%).3 Phone no-8763817256 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 467 A study conducted by RaoBt et al in chandigarh, for our study purpose] & 4 pregnant women from had observed that maternal and child health indicators each session ie total of 100 were included for outcome among slum people showed 2–3 times worse conditions evaluation. than those of in the urban areas. 4 Sampling method : Convenient sampling was used So keeping in mind, the health of the urban poor ; to select pregnant women for the study purpose. Government of India had launched the National Urban Study tool: Data collected by semi-structured, Health Mission (NUHM) on 2013 in the urban areas on pre-tested checklist which includes questionnaire’s the lines of the VHND which will address the health of regarding the presence of service providers at the session the urban poor by facilitating equitable access to available site, availability of required equipment’s and the direct health facilities by rationalizing and strengthening the observation of service provision at the site and the existing capacity of health delivery system. benefits of the services availed by the beneficiaries. The NUHM framework highlights the need of Data collection method: UHND sessions were convergence between ICDS and health where by MAS/ conducted at AWC on every Tuesday and Friday of each Urban ASHA in coordination with the ANM would month. On each week on this 2 days we visited the AWC organize Urban Health and Nutrition day in close andtaken the detail information’sregarding the services coordination/collaboration with the Anganwadi Worker availability with the help of checklist having various (AWW). It is envisaged that UHND would serve as a questionnaire and also by in-depth interview after taking common platform to deliver maternal, child health prior consent from ANM & the pregnant women. care, nutrition and WASH services to the urban poor population. Data analysis: It was done using statistical software SPSS VER.17. All the data were analysed by frequency It would help in delivering health care services at and percentage. The categorical variables difference was the door steps of the un-served and underserved urban found out by using chi-square. The difference was said population thereby leading to an improvement in the to be significant if p-value is <0.05. RMNCH +A indicators. This study was formulated against this background with the Objectives :1) To Ethical clearance taken from IEC committee of the assess the availability of resources for providing maternal institution of VIMSAR,Burla. health services in the study area. 2) To determine the utilisation pattern among the beneficiaries at session Operational definitions : sites.3) To study the association of socio-demographic Input and process indicators were evaluated by characteristic’s of the beneficiaries with the utilisation observational method and outcome indictor assessed by of services by them. in-depth interview of the beneficiaries. Methodology Input indicators -assessed by : Observing the display It was an observationalcross-sectional study carried of IEC banner, availability of various instruments, out in the UHND sessions being conducted under UHTC medicines, MCP card available with the beneficiaries, of Burla for a period of 3months i.e August-October maintenance of registers at session sites on the day of 2019. visit. Study population : Pregnant women who came to Process indicators -assessed by : Observing various the session sites for availing the services on the day of activities carried out by the health workerstowards the visit wereincluded. All the sessions were included. beneficiaries on the day of visit to the UHND session sites. Sample size : 25 UHND session sites were taken for input and process evaluation [ Under VSS Medical Outcome indicators -assessed by: Utilization of the college supervision total of 25 UHND session were services given at UHND by the beneficiaries conducted and all the 25 UHND sessions were included 468 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 v Utilisation of the services by the beneficiaries : and score value of 0 given to those who are not aware or have any knowledge about it.So total score was 7. We included 7 parameters to assess the utilisation of the services by beneficiaries i.e are :Awareness about the Adequate : If score value >4 &Inadequate: If score importance of IFA tablets,knowledge regarding proper value ≤3. diet and personal hygiene, aware about the danger signals, aware of exclusive breast feeding, aware about Results contraception and its usage, aware about complementary Out of 25UHND session being conducted under feeding & choosing the place of delivery. UHTC,Burla it was found out that 24 i.e (96%) of session sites were conducted as per micro-plan. Each parameter are given a score of 1 if the beneficiaries have awareness/knowledge regarding it Table I: Mobilization of the beneficiaries to the UHND session site done by : (n=25) Beneficiaries mobilised by : Frequency (%) ASHA 16 (64%) AWW 2 (8%) AWH 7 (28%) TOTAL 25 (100%) Table I suggest that majority of beneficiaries were mobilized to the session sites by ASHA i.e. (64%) followed by 7(28%)Anganwadi Helper. Table II : Input Indicators assessed at UHND Session site : (n=25) Indicators Yes No Display of IEC banner at session site 20(80%) 5 (20%) Prior hand information given to beneficiaries 23 (92%) 2(8%) Beneficiary list available with the health workers 24 (96%) 1(4%) Table IIillustrates that display of IEC banner was at 80% of session sites while prior hand information to beneficiaries and beneficiary list available with health workers was 92% and 96% respectively on the day of visit to the session site. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 469 Fig I:Availability of variousinstruments at UHND Session sites (n=25) Figure.I demonstrates that in this study BP instrument, weighing scale, stethoscope, were available at 96% of the sessions. Fetoscope was not available at all the session sites while measuring tape and gloves were available at 56% and 68% of session sites. Fig II. Medication availability at UHND session site (n=25) According to Figure II., Chloroquine tablets were available only at 8% session sites followed by paracetamol tablets (32%) and 48% condoms. Still there is need for increase in the availability of medications from government aspect’s on regular basis so that availability must be 100%. 470 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Fig III. Availability of MCP card and maintenance of Register at UHND Session site (n=25) Fig IV. Activities observed on the day of visit to the UHND session site i.e(Process indicators) (n=25) Figure IV. shows that registration of pregnant women, history taking, weigh measurement & T.T were done at most of the sessions. In about 96% of the sessions BP measurement was done.FHS auscultation was not done in any session site due to absence of fetoscope while Antara counseling was done only at 36% session site. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 471 Fig V. Utilization of services by benefi ciaries (n=100) Table III : Association of Socio-demographic characteristics with the utilization of services by the benefi ciaries Utilization of services Socio-demographic P-Value Total characteristics Adequate Inadequate Chi-Square (X2) 1) Age of benefi ciaries <19years 5(5%) 20(20%) 25(25%) 19-25 years 21(21%) 18(18%) 39(39%) P=10.866 >26 years 22(22%) 14(14%) 36(36%) X2=0.004* Total 48(48%) 52(52%) 100(100%) 2) Literacy status of benefi ciary Illiterate 12 (12%) 31(31%) 43(43%) Primary 13(13%) 13 (13%) 13(13%) Secondary 16(16%) 3(3%) 3(3%) P=17.491 X2=0.001* Higher secondary & above 7(7%) 5(55) 12(12%) Total 48 (48%) 52(52%) 100 (100%) 472 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Cont... Table III : Association of Socio-demographic characteristics with the utilization of services by the beneficiaries 3) Occupation of beneficiaries Home-maker 20(20%) 33 (33%) 53(53%) Working lady 28(28%) 19(19%) 47(47%) P=4.760 X2=0.029* Total 48(48%) 52(52%) 100(100%) 4) Family type Nuclear 22(22%) 38(38%) 60(60%) Joint 26(26%) 14(14%) 40(40%) P=7.719 X2=0.005* Total 48(48%) 52(52%) 100(100%) Table III suggests that that those beneficiaries whose age was >26 years, having educational qualification more than primary level, who were working lady and those belonging to joint family had adequate utilisation of services. The group difference was found to be significant with chi-square value as 10.866, 17.491,4.760 & 7.719 respectively with (P<0.05). Discussion Study conducted by Mehta et al (5) had observed that all 19 sessions were held as per micro-plan at the UHND sessions aims to provide a basket of health mentioned session sites. Beneficiaries were mobilized and nutrition services along with counselling to the by the urban Accredited Social Health Activist (ASHA) community through community involvement on a pre- or Anganwadi Helper (AWH) at all session sites visited; designated day, time and place, in every urban slum however, at only 10 i.e (52.6%) sites, the beneficiaries areas throughout the country. were informed a day ahead of the session. Mamta Day In our study we found out that out of 25, 24i.e banner was displayed at (89.4%) of session sites. Only (96%) of session sites were conducted as per micro-plan. 15 sites had a list of due beneficiaries. Display of Mamta DayIEC banner at the session site is Contrary to this, in another study conducted by necessary, so that the nearby people can come to know Parmaret al. (6) in rural area of Vadodara district has the exact location of the session site. Display of banner found out that the beneficiaries were informed 1 day should be at such place which can be visible to all. It was before the Mamta Day at almost 93% session sites. displayed at 80% of session sites on the day of visit in our study. The equipment’s and logistics are quite essential and plays a pivotal role in ensuring service delivery. In Mobilization of beneficiaries is one of the important this study BP instrument, weighing scale, stethoscope, activities,which is a reminder to the beneficiaries to were available at 96% of the sessions. But haemoglobin come to the Anganwadicenter for availing the services. meter,urine examination kit, gloves and measuring tape Majority of beneficiaries were mobilized by ASHA were available in 92% ,84%,68% and 56% of sessions i.e. (64%) followed by 28%Anganwadi Helper. while respectively. Where asfetoscope is unavailable at all the prior hand information to beneficiaries and beneficiary session sites. MCP cards were available in 96% of the list available with health workers was 92% and 96% sessions and maintenance of registers were also done at respectively on the day of visit to the session site. 96% of sites,it was observed that in those sessions. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 473 Though privacy is essential to be maintained during Another study conducted by Kotecha et al.(8) health checkups, it was observed in our study that bed revealed in his study that in 95.6% sessions, pregnant with screen/curtain was not available at any sessions and women were weighed and weights were recorded. BP of abdomen checkup could not be done because of lack of pregnant women was measured properly and recorded privacy of women. in 90% of session sites. Advice for next antenatal check-up was provided along with dietary and relevant Medicines like IFA i.e (92%), calcium (96%),OCP counselling in 63.3% of session sites. No session sites (100%),deworming tablets (96%) were present in most performed abdominal palpation due to lack of privacy of the sessions but paracetamol tablets &chloroquin which is similar with the finding of our study. tablets were supplied in less amount i.e (32%)&(8%) respectively. According to National Family Health Survey-III data,(9) blood and urine tests were conducted for 60% In a study by Mehta et al in Vadodara city, Gujarat and 58% of women, respectively. shows supply of MAMTA (MCP) cards were available at most of the UHND sessions. Iron and folic acid (IFA) It was observed in the study by Kotecha et al.(8) tablets and plain folic acid tablets was available only that breastfeeding advices&family planning counselling at 9 and 2 session sites respectively out of 17 sessions. were not given to any pregnant women in any session The abdominal examination of the woman by abdominal sites which is in contrary to our study finding. palpation including auscultation of fetal heart sounds In our study it was found that service utilisation were not performed at any session site. Also no separate is inadequate in 48% of the beneficiaries and adequate curtains or arrangements were available for ensuring among 52%. As age increases utilisation of services privacy of women being examined at any of the session adequate. sites which were similar with the finding of our study. (5) It was observed that those beneficiaries whose age was >26 years, having educational qualification more Regarding maternal service, registration of pregnant than primary level, who were working lady and those women, history taking, weigh measurement& T.T belonging to joint family had adequate utilisation of were done at most of the sessions. In about 96% of services. The group difference was found to be significant the sessions BP measurement was done. Haemoglobin with chi-square value as 10.866, 17.491,4.760 & 7.719 estimationwas done at 92% of session and IFA tablets respectively with (P<0.05). given at 92% of sites respectively. Counselling to the beneficiaries regarding personal hygiene, danger signals, Conclusion on JSY/Mamataschem, family planning & on EBf were done at 88%,68%,88%,92%,100% respectively. Satisfactory maternal services were provided in Antaracounselling done in (36%) of the sessions only. many session sites, but still there is some lacuna in the The abdominal examination and FHS auscultation of the services. With regard to the availability of instrument & woman were not performed at any session site. logistics, although majority of the essential items were found to be available, focus needs to be given to abdominal (7) Study conducted in Suratcity by Gandhi et al had examination and FHS auscultation, since they were not found out that 91.8% of pregnant women at the session practised at many sites. Counselling on anatra must sites were weighed and weight was recorded . BP of be emphasised. Effective training and retraining of all pregnant women was measured properly and recorded female health workers, ANMs, and Anganwadi workers in 40 i.e (65.57%) of session sites. Nearly 88.5% of the at regular interval is required for morebetter outcome. total ANCs observed were given IFA tab. Health and Regular supervision and monitoring of all sessions must nutritional advice were given to 90.16% of the ANC be held at the health-care facilities according to the observed. However in terms of session sites only in supervision plan. All channels of communication should 8.11% sites anaemia examination was done. be used to make UHND session a highly visible public health activity for maternal survival. 474 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Conflict of Interest- None. during health and nutrition day (Mamta Day) in urban slums of Western India. Journal of Family Funding – No. Medicine and Primary Care. Volume 6 : Issue 2 : April-June 2017.Pg- 411-415. References 6. Parmar A, Parmar N, Pandya C, Mazumdar VS. 1. Guideline for Urban Health and Nutrition Day Proces evaluation of routine immunization (RI) (UHND) in Urban areas of Odisha. Mission and growth monitoring services during Mamta Directorate National Health Mission, Odisha Day (Village Health and Nutrition Day) in Sinor Department of Health & Family Welfare, block of Vadodara District, Gujarat, India. Natl J Government of Odisha. Community Med 2014;5:378‑382. 2. Census of India 2011. Available at: http:// 7. Gandhi S J1, Dabhi M , Chauhan N, Kantharia S. censusindia.gov.in/2011-provresults/paper2/data_ Assessment of maternal and child health services files/india/Rural_Urban_2011. during Mamta days in urban areas of Surat City. 3. Government of India, Planning Commission. Report International Journal of Medical Science and Public of the expert group to review the methodology Health | 2016 | Vol 5 | Issue 06.:1199-1203. for estimation of poverty, Government of India 8. Kotecha I, Singh MP. Process evaluation of health Planning Commission. 2009; Available at: http:// and nutrition day (Mamta Day) in urban slum areas planningcommission.nic.in/reports/genrep/rep _ of Bhavnagar Municipal Corporation. National pov.pdf. Journal of Integr Respiratory Medicine. 2012;Vol 4. Rao BT, Thakur JS. Vulnerability assessment in 3,issue(1) ,Pg:111–114. slums of union territory, Chandigarh. Indian J 9. International Institute for Population Sciences Community Med. 2007;32(3): 189–91. (IIPS) and Macro International. National Family 5. Mehta K, Pandya C, Chavda P , Solanki P. Process Health Survey (NFHS-3), 2005–06. Mumbai, India: evaluation of child health services at out reach sites IIPS, 2007. DOI Number: 10.37506/ijphrd.v12i1.13894 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 475 Food Insecurity and Its Association with Nutritional Status among Women of Reproductive Age Group in Noakhali District, Bangladesh Syeda Saima Alam1, Md. Rhead Hossain2, Md Abdullah Al Mamun3, Md. Nahian Rahman4, Tanzina Akhter5 1Lecturer, Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh, 2MS, Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh, 3Assistant Professor, Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh, 4 MS, Institute of Nutrition and Food Science,University of Dhaka, 5BSc, Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh Summary Objectives: To investigate food insecurity and its association with nutritional status among women of reproductive age group in Noakhali District, Bangladesh Study design: It is a Cross-sectional study in nature. Methods: This study was a primary analysis of 400 reproductive aged women with a structured questionnaire. We carried out frequency tabulation, binary and multivariate logistic regression of study variables to achieve the study objective. Results: Prevalence of HFIAS was 66.30 with 11.00%, 41.8%, and 13.5% mild, moderate, and severe food insecurity, respectively and underweight prevalence (BMI < 18.5) was 14.00%. Respondents who had completed secondary level of education (AOR =0.448, 95% CI: 0.226,0.885) and SSC and higher level of education (AOR =0.222, 95% CI: 0.060,0.819) had less odds of food insecurity. Woman whose family’s food expenditure level was between 10000 to 20000 taka (AOR =0.280, 95% CI: 0.151,0.518) and > 20000 taka (AOR =0.034, 95% CI: 0.004-0.2999) had less odds of food insecurity. When the household head were businessman, respondents had less odds of food insecurity (AOR =0.184, 95% CI: 0.037, 0.912). This result has shown that 30–39-year-old women (AOR =0.353; 95% CI: 0.181, 0.686) and more than 40 years old women had less odds (AOR =0.371; 95% CI: 0.176, 0.783) of underweight. Respondents with had completed SSC and higher level of education had less chance (AOR =0.273; 95% CI: 0.101, 0.741) of being underweight. Women those were from severe food insecurity households were more likely to be underweight (AOR =1.595, 95% CI: 0.789, 3.226). Conclusions: Effort should be made to provide essential social services such as education and health promotion intervention to overcome the immediate consequence of food insecurity and under nutrition which will help to defeat the current condition and will help to achieve active and healthy life. Keywords: Food insecurity, nutritional status, women, Noakhali District, Bangladesh Corresponding author: Introduction Syeda Saima Alam Lecturer, Department of Food Technology and Food insecurity is a condition in which people Nutrition Science, Noakhali Science and Technology experience limited or uncertain physical and economic University,Noakhali, Bangladesh. access to adequate, safe, and nutritious food to meet E-mail: [email protected] their dietary requirements or food preferences for a 476 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 healthy, productive and active life. Food insecurity, by descriptive statistics. Bivariate logistic regression in both developing and developed nations, is a major analysis was done to identify the factors that affect public health problem and it has been associated with the participant’s food insecurity and nutritional status. increased risk for poor nutritional status and adverse Statistically significant factors from bivariate logistic health outcomes 1,2. Despite significant economic regression analysis were included in the multivariate growth and poverty reduction, about 35 percent of the regression model to identify the independent predictors population of Bangladesh remains food insecure, with of participant’s food insecurity and nutritional status. around 10 percent of ever-married women reported as Data analyses were performed in SPSS version 25.0 and moderately or severely food insecure3. Elevation of a P-value of less than 0.05 and 95% CI was considered sea level, depletion of arable land, frequent flooding, statistically significant for all tests. and extreme weather patterns, due to- climate change, Study setting and design: increase the threats to food security. Under nutrition is exacerbated by poor dietary diversity, with 70 percent A cross-sectional study was conducted among of the diet comprising cereals, and inadequate protein reproductive-aged (15 to 49 years) women at Noakhali 4 and micronutrient intake . A woman’s nutritional District, Bangladesh. The interview was carried out status, which contributes to an intergenerational cycle based on a pretested and structured questionnaire to of malnutrition and poverty, is significant both as a collect the data. Simple random sampling was used to predictor of her overall health and as an indicator of include the respondents in the sample. A sample size of 5 pregnancy outcome for both mother and child . Due 400 households was estimated based on the following to differential care giving practices, gender inequality formula: in decision making related to household production and consumption and lesser access to formal healthcare women’s nutritional status lags behind 6.In Bangladesh, 50 percent of pregnant women and 40 percent of non- Here, sample size (n), statistic corresponding to pregnant/non-lactating women suffer from anemia, level of confidence (Z) which was assumed as 1.96 and 22 percent of non-pregnant/non-lactating women are prevalence of food insecurity (p) which was found to be deficient in B12 and 57 percent of non-pregnant/non- 33 % in Bangladesh 11 and Precision,(d) was 0.05. lactating women are zinc deficient 7. Furthermore, 19 percent of reproductive aged women are underweight Finally, adding 10% none response rate, the sample (BMI < 18.5) 8. Poor sanitation and hygiene practice size was determined to be 374 ≈ 400. leads to diarrhea and other infectious diseases which also contribute to under nutrition 9. Malnutrition among Result women affects not only their own health but their children A total 400 households participated in the study. as well because a undernourished woman is going to The majority (52.5%) of the respondent were married. bring forth an undernourished child allowing the cycle Most (35.8%) of the respondents age were between 10 of undernourishment to be repeated over generation . 20–29 years. Majority (61.3%) of household head had completed SSC & higher education and 35.5% of the The relationship between household food insecurity household head were businessman. The majority (72.8%) and nutritional status of women in Noakhali is not of the respondents were housewives. Most of Household properly identified; hence, the objective of this study is food expenditure were less than 10000.In our study it was to find out the prevalence of household food insecurity found that 14% respondents were underweight, 48.5% and maternal nutritional status in Noakhali district, were normal and 29.8% of the women were overweight Bangladesh and 7.8% were obese. 38% of the respondents HDDS Methodology were low, while 41% & 21% respondents had moderate & high HDDS. 33.8% household were food secured, Statistical analysis: while 11%, 41.8% & 13.5% households experienced General characteristic of the subjects were identified mild, moderate & severe food insecurity, respectively. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 477 Table 1: Multivariate analysis of factors associated with food insecurity in households of the Noakhali District, Bangladesh. (n= 400) Variables COR (95% CI) AOR (95% CI) Age of respondents(years) (15-19) 1 (20-29) 0.802(0.478-1.347) (30-39) 1.136(0.612-2.109) ≥ 40 1.071(0.554-2.069) Education level of respondents Primary 1 Secondary 0.390(0.241-0.632) ** 0.448(0.226-0.885) * SSC & higher 0.148(0.067-0.326) ** 0.222(0.060-0.819) * Occupation of respondents Housewife 1 Job holder 0.516(0.176-1.511) Laborer 1.173(0.712-1.934) Education level of the household head Primary 1 Secondary 0.342(0.198-0.592) ** 0.601(0.304-1.188) 0.139 0.516 SSC & Higher (0.056- (0.171-1.560) 0.343) ** 478 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Cont... Table 1: Multivariate analysis of factors associated with food insecurity in households of the Noakhali District, Bangladesh. ( = 400) 푛 Variables COR (95% CI) AOR (95% CI) Occupation of household head Laborer 1 Farmer 0.145(0.032-0.649) * 0.324(0.067-1.572) Businessman 0.091(0.020-0.421) ** 0.184(0.037-0.912) * Job holder 0.203(0.045-0.919) * 0.350(0.073-1.681) Marital status of respondents Never married 1 Married 0.995(0.615-1.612) Number of children of respondents ≤2 1 >2 1.384(0.805-2.378) Family’s food expenditure level (TK) <10,000 1 10,000-20,000 0.278(0.177-0.436) ** 0.280(0.151-0.518) ** >20,000 0.071(0.019-0.259) ** 0.034(0.004-0.299) ** *p value<0.05, **p value<0.01 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 479 Bivariate logistic regression analyses have Binary logistic regression explored predictor identified a significant association between household variables of under- weight (BMI < 18.5), where age of insecurity and education level of respondent family’s the female respondent, education level of respondents food expenditure level, education and occupation of & food insecurity were significant predictors of household heads. Statistically significant factors from underweight (Table 3). Statistically significant factors bivariate logistic regression analysis were included from bivariate logistic regression analysis were in the multivariate regression model to identify the included in the multivariate regression model to identify independent predictors of food insecurity at the the independent predictors of food. Therefore, age, household level. Hence, it was found that the education education level and household food insecurity status of level of respondents, family’s food expenditure level the respondents showed a significant association with and occupation of household heads were significantly nutritional status of the respondents. and independently associated with food insecurity This result has shown that 30–39-year-old women Respondents who had completed secondary level of (AOR =0.353; 95% CI: 0.181, 0.686) and more than 40 education (AOR =0.448, 95% CI: 0.226,0.885) and SSC years old women had less odds (AOR =0.371; 95% CI: and higher level of education (AOR =0.222, 95% CI: 0.176, 0.783) of underweight compared to 15–19-year- 0.060,0.819) had less odds of food insecurity. Woman old women. Respondents with had completed SSC and whose family’s food expenditure level was between higher level of education had less odds (AOR =0.273; 10000 to 20000 taka (AOR =0.280, 95% CI: 0.151,0.518) 95% CI: 0.101, 0.741) of underweight when compared and > 20000 taka (AOR =0.034, 95% CI: 0.004-0.2999) to the respondents who had completed primary level of had less odds of food insecurity than respondents whose education. Women who were from severe food insecurity family’s food expenditure level was <10000 taka. When households were more likely to be underweight (AOR the respondent’s household head were businessman, =1.595, 95% CI: 0.789, 3.226) then women who they had less odds of food insecurity (AOR =0.184, 95% belonged to the food-secured households. CI: 0.037,0.912). Table 2: Multivariate analysis on underweight among reproductive age woman ( = 400) Variables COR (95% CI) AOR (95%푛 CI) Age of respondents(years) (15-19) 1 (20-29) 0.710(0.426-1.182) 0.690(0.408-1.167) (30-39) 0.437(0.231-0.827) ** 0.353(0.181-0.686) ** ≥ 40 0.549(0.284-1.064) * 0.371(0.176-0.783) ** Education level of respondents Primary 1 Secondary 0.801(0.518-1.238) 0.634(0.382-1.051) SSC & higher 0.346(0.136-0.883) ** 0.273(0.101-0.741) ** 480 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Cont.. Table 2: Multivariate analysis on underweight among reproductive age woman ( = 400) 푛 Marital status of respondents Never married 1 Married 0.803(0.498-1.293) Occupation of respondents Housewife 1 Job holder 0.572(0.156-2.097) Laborer 1.223(0.754-1.983) Number of children of respondents ≤2 1 >2 0.723(0.428-1.222) Education level of respondent’s husband Primary 1 Secondary 1.038(0.599-1.798) SSC & Higher 0.792(0.378-1.656) Occupation of respondent’s husband Laborer 1 Farmer 0.461(0.182-1.166) Businessman 0.700(0.265-1.852) Job holder 0.658(0.263-1.645) Category of HDDS Low 1 Moderate 0.999(0.626-1.595) High 0.888(0.501-1.573) Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 481 Cont... Table 2: Multivariate analysis on underweight among reproductive age woman ( = 400) 푛 Food security category Secure 1 Mild food insecurity 1.422(0.685-2.954) 1.291(0.612-2.727) Moderate food insecurity 1.542(0.940-2.531) * 1.299(0.772-2.185) Severe food insecurity 1.750(0.898-3.410) ** 1.595(0.789-3.226) ** *p value<0.05, **p value<0.01 Discussion the chance of job opportunities and higher level of income that in turns decreases the food insecurity level. A total of 842 million people in or approximately Education also increases the knowledge about nutrition one in eight people in the world, were estimated to be and hygiene that has positive effect on decreasing the suffering from chronic hunger, regularly not getting household food insecurity level sufficient food to lead an active and healthy life 12.Despite the importance and worldwide concern about Woman whose family’s food expenditure level food insecurity and malnutrition, this is the first study was between 10000 to 20000 taka (AOR =0.280, 95% at the Noakhali District, Bangladesh to identify the rate CI: 0.151,0.518) and > 20000 taka (AOR =0.034, 95% and explore factors associated with food insecurity and CI: 0.004-0.2999) had less odds of food insecurity than malnutrition. From the findings of the present study it respondents whose family’s food expenditure level was was revealed that the prevalence of HFIAS was 66.30 less than10000 taka. It has found in different studies that with 11.00%, 41.8%, and 13.5% mild, moderate, and when the food expenditure level of a particular family severe food insecurity, respectively, which was higher is high they had less chance of having food insecurity than other study result where researcher found that the 17,18. When a household spend more money on food, food insecurity rate was 55.5% 13. they can enjoy diversified and nutritious food for all members according to their need that in turns lower the It was found that the education level of respondents, food insecurity on that particular household. Another family’s food expenditure level and occupation of determinant of household food insecurity of women was household heads were significantly and independently occupation of household head. When the respondents associated with food insecurity. household head were businessman, they had less odds Respondents who had completed secondary level (A0R:0.184; CI:0.037-0.912) of food insecurity .This of education (AOR =0.448, 95% CI: 0.226,0.885) result is consistence with previous studies19,20.That and SSC and higher level of education (AOR =0.222, reason could be as the businessman earns more they 95% CI: 0.060,0.819) had less odds of food insecurity. spend more money for food purchasing. Researcher found in Ethiopia that respondent who have In this study, among the study population the rate completed secondary level of education were less likely of underweight was 14%.This result was lower than (AOR 0.192; CI:0.022 – 1.43) to be food insecure14.It previous studies 19,21 was found in Kenya that respondents who completed SSC & higher level of schooling were less likely This study found that 30–39-years old women (AOR: 0.345; CI:0.082 – 1.43) to be food insecure15. (AOR =0.353; 95% CI: 0.181, 1.686) and more than 40 A study in America, found that the women attaining years old women had less odds (AOR =0.371; 95% CI: college degrees or higher had significantly lower odds 0.176, 0.783) of underweight compared to 15–19-years of food insecurity16. Higher level of education increases (adolescent) women. This result is consistence with 482 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 previous studies. 22–24. Adolescent girls are particularly overcome immediate consequence of food insecurity vulnerable to malnutrition because they are growing and under nutrition which ultimately increase human faster than at any time after their first year of life. They capital. Strengthening micro finance and small business, adequate food to support the adolescent growth spurt designing strategies of food security program, awareness and meet the body’s increased demand at the time of creation on impact of population, stabilization of food menstruation. If they become pregnant, they are at markets/prices and income generating activities should greater risk of various complications. If they don’t get be encouraged and furthermore promotion is needed to enough food in this period they become malnourished. ensure building up of assets for food insecure households in the study area. Respondents who had completed SSC and higher level of education had less odds (AOR =0.273; 95% Ethical consideration: CI: 0.101, 0.741) of underweight compared to the This study was approved by Ethical Review Board of respondents who had completed primary level of Noakhali Science and Technology University, Noakhali. education. Researchers found in that respondents who The researchers clarified the objective of this research completed higher level of education had less odds (AOR and obtained informed consent from the respondents. =0.345; 95% CI: 0.088, 1.47)of 25,26. If the woman become educated, they become aware of their rights and Availability of data and materials: can influence decision making on their household which impart a positive impact on their nutritional status. The datasets generated during and/or analyzed during the current study are not publicly available due to In this study it was found that women who were from protect privacy of the respondents but are available from severe food insecurity households were more (AOR: the corresponding author on reasonable request. 1.595, CI:0.789, 3.226) likely to be underweight then women who belonged to the food-secured households. Funding: Partial funded by NSTU research cell. Researcher found in India that women who were from Competing Interest: All Authors declare to have severe food insecurity households were more (AOR: no conflict of interest. 1.315, CI:0.111,15.68) likely to be underweight then women who belonged to the food-secured households References 11,27. This may indicate that household food security is 1. Abdu J, Kahssay M, Gebremedhin M. Household a prerequisite for nutritional status. When the household Food Insecurity, Underweight Status, and become food insecure, the members of that house limit Associated Characteristics among Women of their required dietary intake and become malnourished. Reproductive Age Group in Assayita District, Afar Conclusion Regional State, Ethiopia. J Environ Public Health. 2018;2018:8. In this study it was found that education level of 2. Hamad H, Khashroum A. 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Situation Analysis of Trends and Ways Forward. 2001;131(10):2670–6. World Bank; 2019. 484 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13895 Nutritional Status of Under-five Children among Urban Slum Dwellers in Dhaka City, Bangladesh Tanjina Rahman1*, Md. Abdullah Al Mamun1, Susmita Ghosh1, Shakil Ahmed2, M. Akhtaruzzaman3, Fahmida Karim Munni4, Sumaiya Chowdhury5 1Assistant professor, 2Student, Dept. of Food Technology and Nutrition Science, Noakhali Science and Technology University, Bangladesh, 3Professor, 4Student, Institute of Nutrition and Food Science, University of Dhaka, 5Student, North South University, Bangladesh. Abstract Background Childhood malnutrition is a leading public health issues in Bangladesh. Present study focused on current nutritional status among underprivileged children (0 to 59 months), living in selected slum areas of Dhaka city. Methods Data were collected from 138 under-five children and their mothers in a cross-sectional study using simple random sampling from two slums (Mirbag and Modhubag) of Dhaka city. A structured questionnaire was administered to collect demographic, anthropometric (involving stunting, wasting and underweight) and other information related to nutritional status. Results Anthropometric data revealed, the prevalence of both stunting and underweight was more in female child, 29% and 41% respectively, whereas the prevalence of wasting was more than 50% in both male and female. Qualitative analysis of mother’s food intake revealed that, major portion of diet came from plant source whereas animal sources contributed trivial portion. Tendency to skip meal also reflected poor food intake both in quality and quantity. Conclusion Findings of this study revealed, nutritional status of under-five children is associated with multiple factors contributes to childhood undernutrition and attempts should be taken to improve the nutritional status of this disadvantageous cohort, living in impoverished areas of an affluent city of Dhaka. Key Words: Caregiver, Food intake pattern, Malnutrition, Under-five children Introduction of malnutrition is either directly or indirectly related to the mortality and morbidity of children in developing As malnutrition is not considered as a disease, it countries and under-5 children are the most vulnerable remains a hidden health problem and quietly steals the to be affected by malnutrition(1). Nearly 3 million under- energy, retards growth and development and lowers five children die every year due to malnutrition(2). body resistance to infection. Therefore, the problem Bangladesh is the ninth most crowded nations on the planet(3). Approximately 1,203 people for every sq. Corresponding author: km lives in Bangladesh(4) and Dhaka is the capital Dr. Tanjina Rahman of Bangladesh, one of the most densely populated Assistant professor, Dept. of Food Technology and urban communities on the planet(5). Practically 28% Nutrition science Noakhali Science and Technology individuals of Dhaka city are living in the slums under University Mailing address: 7/E, West Hazipara, entirely hopeless condition(6) and the majority of them Rampura, Dhaka-1217, Bangladesh. are undernourished, unskilled and don’t know about Mobile phone: +8801816676010 the healthy benefit of nourishments(7). Because of poor E-mail: [email protected] sanitation and blocked living with 4 to 5 individuals, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 485 they frequently suffer from diseases like dysentery, 7% children suffered from acute malnutrition, 44% diarrhea, typhoid, dengue and pneumonia(8). from chronic malnutrition and 13% suffered from both acute and chronic malnutrition according to Waterlow Although, Bangladesh has made great progress in classification(18). Ahmed et al. conducted a study on the provision of food for its huge number of residents, the nutritional situation of Dhaka has discussed the still the country encounters issues in meeting the need socio-economic situation. The study showed that in of proper amount of dietary nutrients for each of its the pre-school children, protein energy malnutrition individual(9). Especially, typically innocent, defenseless, (PEM) appeared to be a serious problem. A high rate of vulnerable, and minor children are regularly experiencing advanced vitamin A deficiency along with severe PEM lack of healthy nourishment and malnutrition(10). The has been demonstrated. Slum children below five years nutritional status of these youngsters is an alarming of age had higher prevalence of acute (11%) and chronic hint of the nation’s wellbeing, sustainable nutrition, and (50%) malnutrition. The study also identified that economy. Malnutrition or lack of healthy sustenance poverty, lack of knowledge, illness, lack of sufficient of under-five children is a major issue in slums of services and socio-cultural barriers are the major causes Dhaka(11). Malnutrition is one sort of circumstance of nutritional problem(19). in which long lasting absence of at least one or more nutrient hinders physical turn of events or causes Until recently, Bangladesh’s development has explicit clinical problems, for example low birth weight, been mostly driven in the urban areas, which led to stunting, wasting, underweight, vitamin A deficiency, a large influx of migrants from the rural to the urban iodine insufficiency problem, iron inadequacy anemia, areas. Together with political and economic instability, and so forth(12). Bangladesh is one of the nations with the this influx has forced more people to live below the most elevated rate of children malnutrition(4) and chronic poverty line, concentrated in the slums. In Bangladesh malnutrition is experienced by up to 40% of children most of the slum dwellers do not have access to basic under the age 5 years(13) and the scenario of malnutrition amenities such as potable water, electricity, drainage, is even worse among the slums children in Dhaka city(14). roads, sanitation, education, health care, recreation, Common nutrition deficiency for under five children of and waste disposal facilities. As a result of this, many slums in Dhaka city are Protein-energy malnutrition, urban slum dwellers live in deteriorating conditions iron deficiency anemia, iodine inadequacy problems, that affects human health. The poor nutritional status and vitamin A insufficiency(15) and the principle of slum dwellers creates social and financial burdens explanations behind that is their helpless social, poor to the individual, the family, the community, and the monetary and demographic conditions, including family nation. In this alarming situation, it is important to know income, resources, morbidity, work, absolute family the insight nature of food intake pattern, lifestyle, and expenditure, mother’s knowledge, social organizations, overall nutritional status in the slum community. As cleanliness and sanitation and utilization information(7,8). children are the national wealth. it will be a vital loss for One of the ICDDR,B’s center for Nutrition and Food the nation if we allow them to remain malnourished(20). Security baseline survey in Bangladesh indicated that The present study was carried out in the urban under nutrition is high among young children, 41% of slums of the Dhaka city among under five children. The children were discovered stunted, 33% underweight and objective was to assess the nutritional status of under- 11% wasting(16) . five children in urban slum dwellers. A further objective Bhattacharyya revealed in “Protein-Energy was to identify their dietary habit, immunization status Malnutrition..” that only 3.5% rural Bangladesh children and morbidity pattern and level of knowledge of their below 5 years of age were having normal nutritional caregivers. The study also might be useful as a platform, status according to Gomez classification, 18% suffered on which intervention might solve problems to some from 1st degree, 53% from 2nd degree and 25% from 3rd extent, which may help to take necessary measures degree malnutrition(17). The nutritional survey of rural to combat malnutrition along with economic and Bangladesh (1981-82) also revealed that 36% under educational development and to identify the factors five children were having normal nutritional status related to malnutrition, and formulate appropriate 486 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 intervention strategy to improve the nutritional status of caregivers were not present at the time of data collection under-5 children in Bangladesh. or refused to participate were excluded from the study. Methods Ethical Considerations Study Design, Study Area, Population and Study This work was carried out in compliance with the period ethical guidelines of the Declaration of Helsinki. Prior to the survey, the respondents’ permission was taken, A cross-sectional study including both quantitative and they remained anonymous. Until continuing to and qualitative information were collected. The target fill up the questionnaire, all the participants were told population was under five children and their mothers or about the specific objective of this study. Participants caregivers from the extreme poor households of Mirbag were only able to complete the survey once and could and Modhubag slums in Dhaka city. Their approximate terminate the survey whenever they wished. Anonymity number was around 300. Four and half months were and confidentiality of the data were ensured. Formal required from September 15th, 2018 to January 30th, ethical permission for this research was obtained from 2019 for data collection. The time preceding and the respective authority (Urban Primary Health Care following this period was utilized for data entry and Project or UPHCP local office). analysis and final presentation of the study. Data Management and Analysis Plan Sample Size The data were checked and verified. Specific and Simple random sampling technique was used to appropriate computer based statistical programs such as calculate sample size for this study. The sample size was SPSS version 26 (IBM Corp, NY, USA), and MS Office estimated by considering the prevalence of malnutrition were used for data analysis. A p-value less than 0.05 was among the children aged below or equal to five years of considered statistically significant. urban slums. The sample size calculation were measured by using the Cochrane formulae: Results (21), where, n is the smallest sample Table 1. showed the demographic characteristics size to be achieved; p is the expected prevalence of of study subjects, where it was found that, half of the malnutrition (wasting) children aged below five years in children under study aged between 13 to 24 months or 2 urban which was 10 % or 0.10(5).; q is the proportion of years and only 6% were aged <6 months. Around 27% not being malnourished = 0.90; d is the marginal error = of the children were aged between 6 months to one year 0.05; Z is a statistic for a confidence level of 95% =1.96. and 17% of them were more than 2 years old but less So, n= [(1.96)2*0.10*0.90/ (0.05)2] = 138. Based on the than 5 years. Data were collected from the mothers or sample size determination formula, the required sample caregivers of these children, whose age was primarily size of the study was 138 parents or guardians of under- less than 35 years, only 8% of mothers were <22 years five children. old. Almost half (57%) of these mothers were illiterate Data Collection Tool, Inclusion and Exclusion while the remaining 43% only had primary education. Criteria Considering marital status, 11% of these mothers were widower, while 43% were divorcee. Only 37% A detailed questionnaire of both English and of respondents were reported to be as housewife only, Bengali version, weighing scale (Salter scale), height whereas, 22% of them worked in industry, 12% do small scale, MUAC (Mid upper arm circumference) tape was business and 29% worked as day laborer for their living. used in this study. Extreme poor household’s income Only 35% of study cohort reported the child’s father as less than 3000 BDTK per month (equivalent to US the main earning member in their family, whereas more $50), household with children aged 0-5 years, mothers/ than half of those family (58%) lived by the earning Guardians who were willing to participate in the of child’s mother and only 7% reported to have other study and were able to communicate were considered earning members. When the respondents were asked as inclusion criteria. And children whose mothers/ Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 487 about their housing condition, it was found that, majority half of the respondents (55%) were reported to drink (71%) used to live in houses made of all tin (tin-shaded water as it is from water supply and 45% reported to use house), 18% lived in building and remaining 11% lived ‘boiling’ as water purification method before drinking. in Kancha house (made of bamboo fence). More than Table 1. Demographics of the respondents Parameters n (%) Parameters n (%) Child’s Age (months) Mother’s Occupation ≤6 8 (6) Housewife 51 (37) 7-12 37 (27) Industry workers 30 (22) 13-24 69 (50) Small Business 17 (12) ≥25 24 (17) Day laborer 40 (29) Mother’s Age (years) Main income earner in family ≤22 11 (8) Father 48 (35) 23-28 51 (37) Mother 80 (58) ≤35 76 (55) Son/daughter/other 10 (7) Mother’s Education status Housing condition Illiterate 78 (57) Kancha (Bamboo fence) 15 (11) Primary 60 (43) All tin 98 (71) Marital Status Building 25 (18) Widower 15 (11) Method of water purification Married 63 (46) Boiling 62 (45) Divorcee 60 (43) As it is 76 (55) Data were collected from mothers of 138 U-5 malnourished, 26% were moderately malnourished children living in Mirbag and Modhubag Slums, Dhaka. and rest 9% was severely malnourished and out of 68 female children, 56% were mildly malnourished, 29% Table 2. showed the nutritional status of study were moderately malnourished and rest 15% were subjects where it was found that, there were 51% male severely malnourished. According to their weight for and 49% female child and according to their height age anthropometric measurements (underweight), out of for age anthropometric measurements (stunting), out 70 male children, 63% were mildly malnourished, and of 70 male children, approximately, 66% were mildly 37% was severely malnourished and out of 68 female 488 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 children, 59% were mildly malnourished and 41% was severely malnourished. According to their weight for height anthropometric measurements (wasting), out of 70 male respondents, 33% were mildly malnourished, 57% were moderately malnourished and rests 10% were severely malnourished and out of 68 female respondents, 37% were mildly malnourished, 56% were moderately malnourished and rests 7% were severely malnourished. The differences were not found to be statistically significant. (P>.05). These anthropometric assessment was based on World Health Organization (WHO) 2006 Child growth standards(22). Table2: Nutritional Status of Under-five children participated in the study Male, n (%) Female, n (%) Gender 70 (51) 68 (49) Level of stunting (Height for age) Mild 46 (65.7) 38 (55.9) Moderate 18 (25.7) 20 (29.4) Severe 6 (8.6) 10 (14.7) Level of underweight (Weight for age) Mild 44 (62.9) 40 (58.8) Moderate - - - - Severe 26 (37.1) 28 (41.2) Level of wasting (weight for height) Mild 23 (32.9) 25 (36.8) Moderate 40 (57.1) 38 (55.9) Severe 7 (10) 5 (7.4) Data were collected from 138 U-5 children living in cooking daily. Besides, around 37% subjects were in Mirbag and Modhubag Slums, Dhaka. Test Statistics reported to take egg, 80% took either sweet or sour fruits χ2=2.346, df- 2, P=0.310 for stunting, Test Statistics or both, 40% took either milk or milk products and only χ2=1.623, df- 1, P=0.203 for underweight and Test 25% of them took meat/fish on a regular basis. While Statistics χ2=2.346, df- 2, P=0.310 for wasting. considering their weekly food intake, at least 87% of subjects took egg over a week, 72% took either meat or Figure 1. showed that according to types of food fish and only 62% took milk or milk products even over taken as a balanced diet, 100% of subjects were taking a week. cereals (rice, wheat etc.) and either leafy or non-leafy vegetables or both and 100% of sample used fats/oils Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 489 Figure 1: Food Intake Pattern of the respondents on a daily and weekly basis Figure 2 showed the reporting about number of times meal taken by this study cohort where we found that, almost everyone (94%) took breakfast (94%) and dinner (100%), whereas, only 58% subjects took lunch that means almost half of them skipped lunch, however, 36% of them used to take meal in other time of a day. Figure 2: Respondents taking meal at different times of a day Table 3. showed the dietary habit and level of pregnancy and lactation, 41% of them didn’t take any knowledge of respondents in which according to additional food. Fifty four percent of mothers did breast additional food taken during pregnancy and lactation, feeding to their baby but 46% didn’t. Reporting about about 59% of mothers took additional food during causes of not breast feeding, 76% of mothers reported 490 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 no milk secretion and 24% reported problem in breast. Reporting about use of first ejected breast milk, 67% of According to duration of breastfeeding in full month, mothers reported to give first ejected milk to the baby, 33% of mother’s breast fed their baby for >25 month and and 33% of them reported through away. Around 56% 67% breast fed their baby for 19-24 months. According of mother’s bottle fed their baby and 43% didn’t. Fifty to duration of exclusive breast feeding, 63% of mothers eight percent of mothers gave additional food to their reported to breast fed their baby up to 6 months and baby after 6 months but 42% of samples didn’t do that. 37% only breast fed their baby for less than 6 months. Table 3: Distribution of respondent according to Dietary Habit and Knowledge of caregivers. Caregiver’s responses n (%) Caregiver’s responses n (%) Additional Food taken during pregnancy and Duration of only breast feeding lactation Yes 81 (58.7) ≤6 months 28 (37.3) No 57 (41.3) Up to 6 months 47 (62.7) Total 138 (100) Total 75 (100) Mother Breastfed their baby Use of first ejected breast milk Yes 75 (54.4) Through away 25 (33.3) No 63 (45.7) Given to the baby 50 (66.7) Total 138 (100) Total 75 (100) Causes of not breast feeding Bottle fed their baby Problem in breast 15 (23.8) Yes 78 (56.5) No milk secretion 48 (76.2) No 60 (43.5) Total 63 (100) Total 138 (100) Duration of breast feeding Any additional food given to their baby 19-24 months 50 (66.7) Yes 80 (58.0) ≥25 months 25 (33.3) No 58 (42.0) Total 75 (100) Total 138 (100) Data were collected from parents of 138 U-5 children living in Mirbag and Modhubag Slums, Dhaka Figure 3. showed the reporting of mothers about reported suji, 41% reported smashed potato, 59% of types of additional food given to their baby after six them reported cow’s milk, 17% reported rice powder months of age, where, 28% of mothers reported fruit and only 19% of mothers were reported to give cereals juice, 65% of them reported khichuri, 100% of mothers to their baby. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 491 Figure 3. Types of additional food given after 6 months (weaning) Table 4. showed that according to vaccination status, 100% of children were vaccinated. Reporting about immunization status of the child, 59% reported complete and 41% reported incomplete. According to suffering from any diseases within last 6 months, 62% of subjects were reported to suffer from any disease within last 6 month and 38% weren’t suffering from any disease. Reporting about types of diseases, 36% of children suffered from Acute Respiratory Tract Infection (ARI), 43% had diarrhea and measles, 20% had both fever and diarrhea. Table 4: Distribution of respondent according to Clinical Observation n (%) Vaccination Yes 138 (100) No - Immunization status of the child Complete 81 (58.7) Incomplete 57 (41.3) Suffering from any disease within last 6 months Yes 86 (62.3) No 52 (37.7) Types of diseases Acute Respiratory Tract Infection (ARI) 50 (36.2) Diarrhea+ measles 60 (43.5) Fever+ Diarrhea 28 (20.3) Total 138 (100) Data were collected from parents of 138 U-5 children living in Mirbag and Modhubag Slums, Dhaka 492 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Discussion assess immunization status and morbidity pattern among respondents, the percentage reported in the present study A sensitive indicator of a country’s health, economy were not consistent with the previous study conducted and sustainable nutrition is the nutritional status of the by others.(28,29). slum’s children. Malnutrition is a serious problem and complex condition that may be influenced by multiple This present study was a community-based cross- factors such as- household food insecurity, inadequate sectional study encompassing two small slums (Mirbag dietary intake, lack of education, lack of safe drinking and Modhubag) of Dhaka city and is observational in water and sanitation and poor medical infrastructure nature. Therefore, the results from this study may not throughout the nation(23). Under-five children in slums show a complete diversification of findings which might of Dhaka are considered as the most vulnerable group be present in the entire city. No dietary analysis was done and are at high risk of both morbidity and mortality(11). for study subjects in terms of the quantitative analyses of macro or micronutrients and the questionnaire was used In the present study, the prevalence of stunting was to grasp only a snapshot of the dietary intake pattern of 29% in female and 26% in male child, prevalence of the respondents which is somewhat qualitative in nature. underweight, 37% in male and 41% in female, and the Due to constraints of time and resources, as well as prevalence of wasting was found to be more than 50% limited sample size, results might not truly represent that in both male and female; whereas studies showed that, of the wider city. Several variables were highly sensitive the prevalence of stunting (height-for-age, weight for for which an accurate picture could not be obtained. age, weight for height z-score<2) is 51%, underweight is 47.4%, and wasting is 20.3% in preschool children Conclusion of slum area in Bangladesh(22,24). UNICEF/WHO/World Bank Group revealed Progress against global nutrition Based on the findings of this study, it was revealed targets 2019 that, there is no progress or worsening of that, both under-five children and their mothers’ diet under-five wasting, on course in under-five stunting, predominantly consist of foods from plant origin that some progress in low birth weight, and no progress or also indicates their poor quality of dietary protein intake worsening in exclusive breastfeeding(25). The present from plant sources. This might be a reason for their poor study also reveals that only 54.4% mother breast feed growth and development as well. Some recommendations their baby and only 62.7% mothers exclusively breast can be put forward, such as health educational programs feed their baby. The main reason for not to breast feed for the parents should be organized to increase their level their children is no milk secretion of mothers (76.2%). of knowledge to reduce the prevalence of malnutrition Protein is considered as the building blocks of body but throughout impoverished urban areas in Bangladesh. from their dietary record, consumption of protein source Nutritional supplementation and child health programs, was very low, whereas majority of the respondents which are currently focused on impoverished rural (100%) were reported to take cereals, especially rice and areas, should not exclude informal settlements in urban either leafy or non-leafy vegetables regularly from all areas. An integrated approach should be taken to help food groups that clearly shows that their dietary energy ensuring dietary diversity as well as food security among demand was fulfilled by cereals and it is also correlated urban slum dwellers in Dhaka city. Similarly, Exclusive with another study done in southern part of Bangladesh breastfeeding practice campaign could also be arranged that also evaluate dietary intake pattern of under-five in this part of the country. children and lactating mothers(9). Acknowledgments: Marium Sultana, Farhana Food habit pattern and dietary knowledge among Akter, Nasrin Sultana, Md. Sajjadul Hoque, MS students the respondents were observed and compared with of the department of Food Technology and Nutrition the formerly recorded data to see whether those are Science, Noakhali Science and Technology University. consistent with the present data. To assess dietary habit Conflict of Interests: The authors declare that they and knowledge of mothers, the percentage reported in the have no competing interests. present study differs a little from other studies(26,27). To Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 493 Sources of financial support : This research did 14. Faruque ASG, Ahmed AS, Ahmed T, Islam not receive any specific grant from funding agencies in MM, Hossain MI, Roy S, et al. Nutrition: basis the public, commercial, or not-for-profit sectors. for healthy children and mothers in Bangladesh. 2008;26(3):325. References 15. Kim R, Mejia-Guevara I, Corsi DJ, Aguayo VM, 1. Mclaren D, Read WCJTL. Classification Subramanian SJSS, Medicine. Relative importance of nutritional status in early childhood. of 13 correlates of child stunting in South Asia: 1972;300(7769):146-8. Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and 2. Black RE, Victora CG, Walker SP, Bhutta ZA, Pakistan. 2017;187:144-54. Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low- 16. Ahmed T, Mahfuz M, Ireen S, Ahmed AS, Rahman income and middle-income countries. The lancet. S, Islam MM, et al. Nutrition of children and 2013;382(9890):427-51. women in Bangladesh: trends and directions for the future. 2012;30(1):1. 3. UU EJTWFCC. Central Intelligence Agency. 2014. 17. Bhattacharyya AJWron, dietetics. Protein-energy 4. Herforth A, Jones A, Pinstrup-Andersen P. malnutrition (Kwashiorkor-Marasmus syndrome): Prioritizing nutrition in agriculture and rural terminology, classification and evolution. 1986. development: guiding principles for operational investments. 2012. 18. Hels O, Hassan N, Tetens I, Thilsted SHJEjocn. Food consumption, energy and nutrient intake and 5. Organization WH. Climate change and health nutritional status in rural Bangladesh: changes from country profile 2015: Bangladesh. 2015. 1981–1982 to 1995–96. 2003;57(4):586-94. 6. Holden M, Roseland M, Ferguson K, Perl AJHI. 19. Ahmed FJTSAjotm, health p. Nutritional situation Seeking urban sustainability on the world stage. of Dhaka. 1992;23:59. 2008;32(3):305-17. 20. Kotloff KL, Blackwelder WC, Nasrin D, Nataro 7. Pryer JA, Rogers S, Normand C, Rahman AJPhn. JP, Farag TH, van Eijk A, et al. The Global Enteric Livelihoods, nutrition and health in Dhaka slums. Multicenter Study (GEMS) of diarrheal disease in 2002;5(5):613-8. infants and young children in developing countries: 8. Rahman M, Alam SJBJNFS. Nutritional status of epidemiologic and clinical methods of the case/ children in slums of Dhaka. 2015;5(6):1. control study. 2012;55(suppl_4):S232-S45. 9. Rahim ATM, Bhattachaijee L, Shaheen N. Dietary 21. William GC. Sampling techniques. Canada: John intake pattern of lactating mother and under Willey & Sons Inc. 1977. five children in selected districts of southern 22. Turck D, Michaelsen KF, Shamir R, Braegger Bangladesh. C, Campoy C, Colomb V, et al. World health 10. Haque M, Bhuiyan M, Naser M, Arafat Y, Suman organization 2006 child growth standards and 2007 KJJNHFE. Nutritional status of women dwelling in growth reference charts: a discussion paper by the urban slum area. 2014;1(3):1-14. committee on nutrition of the European society 11. Arifeen SE, Black RE, Caulfield LE, Antelman G, for pediatric gastroenterology, hepatology, and Baqui AH, Nahar Q, et al. Infant growth patterns nutrition. Journal of pediatric gastroenterology and in the slums of Dhaka in relation to birth weight, nutrition. 2013;57(2):258-64. intrauterine growth retardation, and prematurity. 23. Haseen F. Malnutrition among Bangladeshi 2000;72(4):1010-7. women in ultra poor households: prevalence and 12. 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Institute of Population Research and Training …; DOI Number: 10.37506/ijphrd.v12i1.13896 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 495 The Effect of Dried Amnion Membrane Application in the Expression of Platelet Derived Growth Factors in the Healing Process of Stomach Stab Wound (Study on New Zealand Rabbit) Yipno Wanhar1, Fendy Matulatan2, IGB Adria Hariastawa2 1Resident of Surgery, Faculty of Medicine Airlangga University/Dr. Soetomo General Hospital Surabaya, 2Staff of the Pediatric Surgery Division, Department of Surgery, Faculty of Medicine Airlangga University/Dr. Soetomo General Hospital Surabaya Abstract Background: Management of penetrating abdominal trauma, especially those affecting the stomach, keeps developing. Although the technology in the field of surgery is getting more advanced, the risk of complications due to leakage is still common. A lot of research is being done to improve the tissue healing process, including a variety of surgical techniques and material uses. The amniotic membrane is a material that is widely used to help stimulate the healing process. The amniotic membrane contains growth factors, one of which is platelet-derived growth factor (PDGF). PDGF is a major player in the wound healing process. Purpose: To investigate the differences in PDGF levels in gastric rupture repair with dry amniotic membrane as a biological dressing compared to primary repair of gastric rupture without using dry amniotic membrane. Method: This research was an experimental analytical study, using 42 samples of rabbits which were grouped into 2 groups, namely the control and treatment groups. Stab wound of 2 cm by 0.5 cm wide with a depth entire gastric wall in gastric corpus was done and repaired with 4-6 interrupted suture using 5/0 polypropylene monofilament. In the control group, the wound was only sutured and the treatment group, dry amniotic membrane was applicated before suturing. The expression of PDGF was examined from the suture tissue on day-7. Result: Intensity score was obtained in the treatment group with the highest score of 2 with a sample of 11 (52.4%) as well as in the control group as many as 13 (61.9%) samples who had a score of 2. The extension score was obtained in the treatment group with the highest score of 1 with a total sample size of 10 (47.6%) while the control group had the highest score with a score of 0.5 as much as 14 (66.7%). After obtaining the PDGF intensity and extension values, then these two values are multiplied to get the PDGF expression. From the results of the comparison test using the Mann Whitney test, it was found that the difference in PDGF expression was significant between the treatment group and the control group with p = 0.008 (p <0.05). Conclusion: Applying dry amniotic membrane to the wound on the stomach will increase the expression of PDGF in the wound area. Keywords: dry amniotic membrane, PDGF, gastric penetrating trauma Background Corresponding Author: Management of sharp abdominal trauma, especially Yipno Wanhar; those affecting the gastric organs, continues to develop, Dr. Soetomo General Hospital Surabaya; [email protected] in this case laparotomy and closure of defects formed 496 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 after sharp trauma to the stomach1. Wound healing is a complex cellular and biochemical cascade, leading to restoration of the integrity and The approach to repairing injury to the stomach function of a tissue. Under normal circumstances, the depends on the degree of damage to the gastric tissue wound healing process follows a predictable pattern and its location. Gastric injury that covers only part and can be divided into phases. Several types of growth of the gastric wall can be performed seromuscular factors and cytokines are released in this process6. One primary suturing with non-absorbable thread. While for of the growth factors that have an important role in the gastric injury which includes the gastric mucosa, defect wound healing process is platelet-derived growth factor closure can be done by suturing the gastric mucosa with (PDGF). However, in conditions of sepsis, the response absorbable sutures followed by primary seromuscular of platelet-derived growth factor (PDGF) to tissue suturing with non-absorbable sutures. In addition, a damage is decreased and the addition of exogenous stapler can also be used to cover defects in the stomach. platelet-derived growth factor (PDGF) can improve the Even though today, technology in the field of surgery response to tissue damage and can reduce excessive is increasingly advanced, the risk of complications due inflammatory responses during the wound healing to post-suturing tissue leakage is still common. Much process. research has been done to improve the tissue healing process, including various surgical techniques and the The amniotic membrane contains growth factors use of materials (high quality surgical sutures, use of a including epidermal growth factors (EGF), platelet- stapler, control of sepsis with bowel preparation before derived growth factor (PDGF) and transforming growth surgery, use of parenteral nutrition, use of various factor beta. PDGF is a growth factor that first appears sealants, fibrin-collagen patches, etc.), but cannot in the wound healing process which plays a major role prevent the risk of these complications. Therefore, in wound healing and is a major player in the wound research on materials that can be applied locally to speed healing process. The initial function of PDGF is to up the healing process or reduce the risk of leakage is of stimulate the formation and proliferation of fibroblasts. particular concern2. The presence of PDGF will accelerate wound healing. The next function is to induce myofibroblast phenotype. The amniotic membrane is a material that is Meanwhile, EGF only functions in the reepitelialization widely used to help stimulate the healing process. The process. Apart from the amniotic membrane, PDGF is amniotic membrane has been shown to have many uses also believed to be produced by human body tissues.7 in the management of burns, oral cavity reconstruction, bladder, vagina, tympanoplasty, arthroplasty and many There are many advantages to using the experimental more3. The amniotic membrane is the innermost of rabbit animal model. Rabbits are easier to come by and the 3 layers that make up the placenta. The amniotic easier to raise, and closer to primates phylogenetically. membrane is formed by 3 layers: One epithelial layer, a In addition, the cost of managing rabbits is relatively thick basement membrane, and a vascular mesenchymal cheaper than animal models with larger size. All of these layer4. The amniotic membrane contains basal membrane characteristics make the rabbit our experimental model components, growth factors and proteinase inhibitors5. of choice. Therefore, this study used a experimental Research has shown that the amniotic membrane has animal model of male New Zealand white rabbits. antibacterial properties, low immunogenicity, and can Based on the above thinking, the researcher wants to aid in the epithelialization and wound healing process, conduct a study to evaluate differences in PDGF levels inhibit inflammation and scar formation, and increase in t defects angiogenesis4. The amniotic membrane is also easy to obtain, easy to process and distribute. The amniotic Method membrane is obtained during delivery by elective This research is an experimental study with a cesarean section and does not need to kill human randomized control trial study design using rabbits. The embryos for isolation, thus avoiding controversies such experimental rabbits will be divided into two groups, 5 as the use of human cells . each with the same number of samples. In both groups, 2 cm of gastric rupture was performed in the gastric Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 497 corpus and all-layer rupture repair was performed for the rabbit weight variable and p = 0.021 for the with 4-6 stitches one by one using 5/0 monofilament rabbit age variable. This shows that the rabbits in the polypropylene thread. In the PA group, the anastomosis two groups are not normally distributed (p> 0.05, so that was covered with a dry amniotic membrane with a width the data transformation is carried out and the p value is of 2 cm x 3 cm, with the basement membrane facing the obtained <0.05. Therefore, the variables of this study are serous surface of the stomach. The amniotic membrane still not normally distributed and the statistical test used is fixed on the gastric serosa with 2-3 sutures. From is the Mann-Whitney test. U test. these two groups, the specimens were sacrificed on day Rabbits were sacrificed using penobarbital was 7. The 5 mm rupture repair segment was cut, and fixed carried out on the 7th day, then the specimen was in 10% formaldehyde for histopathological examination. taken and fixed with formalin. Measurement of PDGF Results expression is performed by assessing the intensity and percentage of positive cells to evaluate immunoreactivity. The sample of this study involved 42 experimental The intensity of PDGF will be expressed in terms of 0 - 3 rabbits with injuries (rupture) 2 cm long with a width with reference to the intensity of the colored PDGF. The of 0.5 cm with a depth of the entire gastric wall in the extensions of stained cells were expressed as grades 0 gastric body and rupture repair with 4-6 stitches one by for 1 - 9%, 0.5 for 10 - 50%, and 1 for extensions over one using 5/0 monofilament polypropylene thread. . The 50%. The score will be generated by multiplying the sample was further divided into two groups, namely the intensity value by the extension of the colored PDGF. sample with the primary repair group for gastric rupture (without using dry amniotic membrane) and the group In this study, evaluation of the intensity, extension using dry amniotic membrane. In the sample calculation, and expression of PDGF using scoring methods. The 21 samples were obtained for the group without using score with this method is semi-qualitative and the results dry amniotic membrane and 21 samples for the group obtained are the result of subjective observations made using dry amniotic membrane. by the pathologist. Table 1 – Research Subjects Characteristics The intensity score was obtained in the treatment group with the highest score of 2 with a sample of 11 Intervention Control Group Group (52.4%) as well as in the control group as many as 13 (61.9%) samples who had a score of 2.The extension Mean of Age score was obtained in the treatment group with the 9 ± 0,83 9 ± 0,92 (months) highest score of 1 with a total sample size of 10 (47.6%) while the control group had the highest score with a Mean of Weight 2500 ± 183,35 2500 ± 170,71 score of 0.5 as much as 14 (66.7%). (grams) After obtaining the PDGF intensity and extension Based on the table above, it was found that the values, then these two values are multiplied to get the mean age of the study sample in the group without dry PDGF expression. From the results of the comparison amniotic membrane was 9 ± 0.83 months and the group test using the Mann-Whitney test, it was found that using dry amniotic membrane was 9 ± 0.92 months and there was a significant difference in PDGF expression body weight in the group without using dry amniotic between the treatment group and the control group membrane was 2500 ± 183.35 grams and the group with with p = 0.008 (p <0.05). This means that statistically using dry amniotic membrane is 2500 ± 170.71 grams. applying the amniotic membrane to the closure of the The sample characteristics in the basic data of the study abdominal defect can increase PDGF expression. showed that there were significant differences in the characteristics between the weight and age variables of the rabbits in the two sample groups where p = 0.000 498 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Table 2 - Measurement of PDGF Intensity, Extension and Expression between Treatment and Control Groups Sample Groups Measurements P Intervention Group Control Group Intensity 0 - - 1 4 (19.0%) 8 (38.1%) 0.022 2 11 (52.4%) 13 (61.9%) 3 6 (28.6%) 0 (0%) Extension 0 1 (4.8%) 4 (19.0%) 0.014 0,5 10 (47.6%) 14 (66.7%) 1 10 (47.6%) 3 (14.3%) Expression 0 1 (4.8%) 4 (19.0%) 0,5 4 (19.0%) 3 (14.3%) 1 3 (14.3%) 12 (57.1%) 0.008 1,5 3 (14.3%) 0 (0%) 2 8 (38.1%) 2 (9.5%) 3 2 (9.5%) 0 (0%) Based on the results of this study, it was found that process includes regular cell migration and involvement almost all samples in the treatment group had a higher of endothelial cells for angiogenesis (There are various PDGF expression score than the control group. Figure growth factors and cytokines released to maintain wound 5.3 shows a graph of the PDGF expression in each healing. After homeostasis is achieved, the wound will sample from both the control and treatment groups. experience 4 phases of healing, namely the inflammatory The highest PDGF expression score in the treatment phase, epithelialization phase, proliferation phase, and group was 3, as many as 2 samples, and the lowest score maturation phase, where in the proliferation phase, was 0 for 1 sample. While the highest score for PDGF fibroblasts have a major role in tissue proliferation and expression in the control group was 2 for 2 samples, and collagen synthesis (the main protein structure of the the lowest score was 0 for 4 samples. body)8. Discussion Wound healing is a complex process that begins with a disturbance in the integrity of the tissue. Several Gastric repair is a process that involves systemic, types of growth factors are found in the wound healing local, and operative factors that simultaneously influence process which have an important role in this process. the series of wound healing processes. Wound healing Several types of growth factors have been approved for is a form of cellular response to tissue injury or injury use as treatment in humans. These growth factors are and involves the activation of keratinocytes, fibroblasts, PDGF, FGF-2, IGF, and KGF9. PDGF is the first growth endothelial cells, macrophages, and platelets. This factor that appears in the wound healing process. This Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 499 shows that PDGF plays a very important role in this inflammatory phase and damage many cells, whereas process. PDGF acts as a chemotactic factor. The role if there are too many antioxidants such as PDGF and of PDGF here is to attract neutrophil cells, monocytes, not balanced with the amount of oxidants (ROS), it will fobroblasts, and smooth muscle cells to the wound facilitate the infection process in wounds This is because site. In addition, PDGF also plays a role in fibroblast the contaminating bacteria does not kill because there proliferation and production of the extracellular matrix7. are too few oxidants.11 Based on the results of this study, it was concluded In a study conducted by Kaltalioglu et al, in 2012, that there was a significant difference in PDGF it was found that NO, which has a positive effect on expression between the treatment group and the wound healing in low amounts and shows toxic effects control group with a value of p = 0.008. This means in high amounts (as the main oxidant), can be suppressed that in the treatment group the PDGF expression is in the presence of PDGF (as an antioxidant). It is known greater than the PDGF expression in the control group. that NO is produced by several different cell types in Clinically, it means that the group that has greater wounds where there are three different isotypes of nitric PDGF expression has a faster recovery. This is in oxide synthase. Inducible NO (iNOS) is one of these accordance with Werner’s research saying that the three isotypes. Fibroblasts, macrophages, keratinocytes, PDGF level in wounds that did not heal was much less7. platelets increase the number of NO via iNOS. However, PDGF has the greatest role before day 7 of the wound it was found in the study that NO production was healing process. PDGF plays a role in accelerating the significantly decreased by the presence of PDGF-AB initial inflammatory response which will speed up the and PDGF-BB in these cells. The production of nitrite wound healing process. In addition, PDGF is a major is inhibited by PDGF-BB and causes a decrease in the player in the wound healing process.10 formation of iNOS protein so that the production of NO can be suppressed and inflammatory events can also be PDGF has the greatest role before day 7 of suppressed.11 the wound healing process. PDGF plays a role in accelerating the initial inflammatory response which The amniotic membrane itself is known to contain will speed up the wound healing process. In addition, a lot of PDGF, both AA, BB, AB, CC and DD PDGF. PDGF is a major player in the wound healing process10. So that the use of the amniotic membrane itself is the One of the ways PDGF accelerates the wound healing same as applying PDGF to the wound area, because period is by being an antioxidant in wound healing. In this study shows the wound area given by PDGF has a wound healing, Reactive Oxygen Species (ROS) are higher PDGF expression. We suspect that this amniotic produced in large quantities by inflammatory cells and membrane stimulates the expression of PDGF and can cause cellular damage (called “oxidative stress”) by several other growth factors. Rahman’s research in membrane lipid peroxidation, inactivation of sulfidrile 2013, stated that the amniotic membrane is related to enzymes, protein cross-linking, and DNA breakdown. interstitial collagen types I, II and elastin. In addition, Detoxification of ROS can be achieved by a variety the elasticity of the amnion is mainly due to type III of enzymes (eg superoxide dismutase-SOD, catalase- collagen. The mechanical integrity of the amnion is CAT) and non-enzymatic types (eg glutathione-GSH, maintained by interstitial collagen (types I and III) and antioxidant ascorbic acid-AA). However, ROS, which predominate and form parallel bundles. And like hydrogen peroxide (H2O2) and superoxide (O2- there are also collagen types V and VI that connect ), can act as messengers between cells. Production of the filaments between the collagen interstitials and H2O2 itself is required for PDGF signal transduction. the epithelium. The discovery of many components In addition, the production of ROS is important for of the extracellular matrix in the amniotic membrane, eliminating contaminating bacteria in wound healing. in our opinion, is one of the mechanisms causing the Therefore, maintaining a balance between oxidants increased expression of PDGF in the group of mice and antioxidants is very important. Because if there are that were treated with dry amniotic membrane closure. too many oxidants such as ROS and are not balanced In addition to the above mechanisms, Koob et al., Found with the number of antioxidants, it can prolong the a biological component in the dry amniotic membrane 500 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 and its implications for chronic wound healing. In their 4. Uludag M. Citgez B. Ozkaya O. Yetkin G. Ozcan research, Koob et al. find biological components such as O. Polat N. Isgor A. Effect Of Amniotic Membrane growth factors (bFGF, EGF, GCSF, PDGF-AA, PDGF- On The Healing Of Normal And High-Risk Colonic BB, PLGF, TGF alpha and TGF beta 1), Interleukin Anastomosis In Rats. Int J Colorectal Dis. 24; 2009. (IL-4, IL-6, IL-8 and IL-10) and Tissue Inhibitors og pp. 809-17. metalloproteinases (TIMP-1, TIMP-2, and TIMP-3). The 5. Toda A. Okabe M. Yoshida T. Nikaido T. The presence of other active ingredients besides PDGF in the Potential of Amniotic Membrane/Amnion-Derived amniotic membrane makes these ingredients cooperate Cells for Regeneration of Various Tissues. J with each other and accelerates wound healing. In his Pharmacol Sci.105; 2007. pp. 215-28 research, it was also found that in the amniotic membrane, 6. Amstrong D, et all. Basic Principles of Wound levels of PDGF-AA were higher than PDGF-BB.12 Healing. UpToDate Inc; 2018. 7. Werner S. Grose R. Regulation of Wound Healing by Growth Factors and Cytokines. Physiol Rev. Conclusion 83(3); 2003. Pp. 835-70 Application of dry amniotic membrane to the wound 8. Soylu S. Yildiz C. Bozkurt B. Karakus S. on the stomach will increase the expression of PDGF in Kurt B. Kurt A. Amniotic Membrane -Coated the wound area Polypropylene Mesh For The Repair of Incisional Hernia: An Experimental Study In A Rat Model Ethical Clearance: Taken from Ethical Committee With Abdominal Wall Defect. Iran Red Crescent of Animal Research, Faculty of Veterinarian, Airlangga Med J. Vol. 20(3); 2018. pp. 1334-7 University 9. Bilska A . Wound Healing: The Role of growth Factor. Drugs of Today 39 (10); 2003. pp. 787-800 Source of Funding: Self 10. Judith, R., Nithya M., Rose, C., Mandal, A. B. Conflict of Interest : Nil Application of a PDGF- containing novel gel for cutaneous wound healing. Elsivier. 87(1-2). 2010. Bibliography pp.1-8. 1. American College of Surgeons. Advanced Trauma 11. Kaltalioglu K, Coskun-Cevher S, Tugcu-Demiroz Life Support, American College Surgeons, F, Celebi N. PDGF supplementation alters oxidative Chicago; 2018. pp. 357-80. events in wound healing process: a time course study. Arch Dermatol Res. 2013 Jul;305(5):415-22. 2. Ozel SK. Kazez A. Akpolat N. Does A Fibrin- doi: 10.1007/s00403-013-1326-9. Epub 2013 Feb Collagen Patch Support Early Anastomotic Healing 20. PMID: 23423159. In The Colon? An Experimental Study. Tech Coloproctol. 10:233-6; 2006 12. Koob, T. J. et al. ‘Biological properties of dehydrated human amnion/chorion composite 3. Niknejad, H. Peirovi, H. Jorjani, M. Ahmadiani, graft: Implications for chronic wound healing’, A. Ghanavi, J. Seifalian, AM. ‘Properties Of The International Wound Journal, 10(5), pp. 493–500. Amniotic Membrane For Potential Use In Tissue doi: 10.1111/iwj.12140; 2013. Engineering.’ European Cells and Materials 15; 2008. pp. 88-99 DOI Number: 10.37506/ijphrd.v12i1.13897 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 501 Analysis of the Risk Factors for Sexual Dysfunction in Stoma Patients Zuliawati1, Siti Saidah Nasution2, dan Asrizal3 1Master Program, Faculty of Nursing, Universitas Sumatera Utara, Medan, Indonesia, 2 Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Medan, Indonesia, 3 Lecturer, Faculty of Nursing, Universitas Sumatera Utara, Medan, Indonesia Abstract Objective: to analyze the risk factors for sexual dysfunction in stoma patients. Methods: The study was an analytical descriptive design with a cross-sectional approach. Thirty-seven were respondents selected by consecutive sampling. Data were collected using demographic, ASEX scale questionnaires, and questionnaire of risk factors for sexual dysfunction, and Analyzed using chi-square and logistic regression. Results: The results show that there were correlations among fear to performance (p=0.00;RR=14.66), inadequate counseling (p=0.00;RR=33.33), alcohol consumption (p=0.01;RR=10.12), and biological causes (p=0.00;RR=27.14) with prevalence of sexual dysfunction in stoma patients. The results also show that there was not significant correlation among psychosexual trauma (p=0.56;RR=0.37) and socio-cultural factors (p=0.12;RR=4.26). The factors which was most significantly correlated with the prevalence of sexual dysfunction in stoma patients were inadequate counseling (p=0.03;OR=20.84 95% CI=1.25-347.47), alcohol consumption (p=0.04;OR=14.66 95% CI=1.05-204.30), and biological factors (p=0.04;OR=19.45 95% CI=1.09-346.98). Conclusion: The sexual dysfunction in stoma patients is possibly influenced by a variety of factors, the selection of the right intervention plays a very important role to minimize the risks for sexual dysfunction in stoma patients so that the nursing care quality will be improved to be better. Keywords: Sexual dysfunction; Stoma, Risk factors Introduction stomas in the UK, with 21,000 new stomas annually(3). According to Gao et al. in China the formation of a stoma A stoma is an operative opening in the abdomen to is 100.000 per year(4). Data on stoma patients at Adam pass stool or urine into the stoma bag. The stoma can be Malik Hospital Medan in 2016-2018 totaled 334 people. temporary or permanent and depending on which part of the intestine is used(1). Conditions that require stoma The physiological effect of stoma surgery is the surgery are cancer, inflammatory bowel disease, trauma, diversion of disposal from the stomach, resulting in a loss and intestinal obstruction(2). According to Humphreys of sphincter function in controlling the fecal discharge, data shows as many as 102.000 people live with gas, and odor excretion that is beyond the body’s control(5). These changes can hurt mental status and changes in physical status (such as an impaired sexual Corresponding author: function)(6). Sexual need is one of the physiological Zuliawati needs according to Abraham Maslow. When certain E-mail: [email protected] physiological needs in the hierarchy of human needs are Jalan Prof. Maas No.03, Kampus USU, Medan 20155, Sumatera Utara, Indonesia met, then other needs will emerge. If these needs are not met, a person will tend to feel lonely, feel unattended, 502 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 will also experience fear, weakness, low self-esteem, 4) women aged 15-49 years and men aged ≤69 years. anxiety, and feelings of depression. A condition when Exclusion criteria: 1) patients who were not willing to the process of fulfilling needs is disrupted, this will lead be respondents; 2) patients with a stoma who did not to pathological conditions(7). have a partner; 3) history of stoma creation ≤ 21 days; 4) women aged ≥ 49 years and men ≥69 years. According to Sutsunbuloglu and Vural, patients with urostomy were found to have decreased sexual The instruments used in this study were the desire(8). According to Humphreys, data shows that demographic data questionnaire sheet, the sexual 67% of men with stoma experience sexual dysfunction, dysfunction questionnaire, and the sexual dysfunction and 74% of women with stoma experience sexual questionnaire. The demographic data questionnaire dysfunction. Sexual dysfunction can be affected by consisted of the initials of the respondent’s name, age, several factors(3). According to Nair et al., sexual gender, educational level, religion, ethnicity, occupation, dysfunction is significantly associated with alcohol history of stoma surgery, type of stoma, history of dependence. 37% of the study group experienced sexual creating repeated stomas, history of additional illness, dysfunction(9). According to research by Zhu et al. that history of using drugs, history of smoking. The sexual there is a relationship between sexual life guidance and dysfunction questionnaire used the ASEX instrument the occurrence of sexual dysfunction in stoma patients which consists of 5 items, namely sexual drive, arousal, (p <0.000) and there is a relationship between family vaginal lubrication/penile erection, the ability to achieve relationships and the occurrence of sexual dysfunction orgasm, and satisfaction from orgasm. The total ASEX in stoma patients (p <0.000)(10). score is 5-30. The male and female versions differed in the third question, which relates to penile erection/ Based on the results of this study, it is indicated vaginal lubrication. This questionnaire used a Likert that the factors that influence the occurrence of sexual scale with six response options. Sexual dysfunction is dysfunction in stoma patients vary. For this reason, this score ≥19. The ASEX instrument was adopted from study will identify factors that cause sexual dysfunction McGahuey et al. Researchers have obtained permission in patients with a stoma. from the Department of Psychiatry(11), the University of Methods Arizona, and the ASEX instrument has been translated by researchers into Indonesian through the Language The study was an analytic descriptive with a cross- Center of the University of Sumatera Utara. Reliability sectional approach. This study was carried out at Adam using Cronbach’s Alpha on the sexual dysfunction Malik Hospital Medan from Mei to June 2019. Thirty- factors questionnaire was 0.81. The ASEX instrument, seven respondents were involved in this study using Cronbach’s Alpha value was 0.94. Data were analyzed consecutive sampling. Inclusion criteria: 1) patients using chi-square and logistic regression. with a stoma either with colostomy bags or patients with ileostomy bags; 2) patients with families who still have partners; 3) history of stoma creation ≥ 21 days; Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 503 Results Table 1. Characteristics of research respondents (n=37) Characteristics Frequency Percentage (%) Age 26-35 years 4 10.8 36-45 years 15 40.5 46-55 years 7 18.9 56-65 years 9 24.3 > 65 years 2 5.4 Gender Male 30 81.1 Female 7 18.9 Educational level Primary school 8 21.6 Junior high school 6 16.2 Senior high school 20 54.1 University/ collage 3 8.1 Religion Muslim 20 54.1 Protestant 14 37.8 Catholic 2 5.4 Hindu 1 2.7 Ethnicity Bataknese 22 59.5 Javanese 11 29.7 Minangnese 1 2.7 Acehnese 2 5.4 Balinese 1 2.7 Employment Civil officer 4 10.8 Private employee 4 10.8 Entrepreneur 9 24.3 Housewife 7 18.9 Farmer 13 35.1 History of stoma 21 days to 6 months 14 37.8 6-12 months 13 35.1 > 12 months 10 27.0 Type of stoma colostomy 35 94.6 Ileostomy 2 5.4 504 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Cont... Table 1. Characteristics of research respondents (n=37) History of repeated stomas No 32 86.5 Leaky intestinal 4 10.8 Necrosis 1 2.7 History of disease No 25 67.6 Diabetes Mellitus 5 13.5 Hypertension 7 18.9 History of using drugs No 17 45.9 Yes, namely : 20 54.1 Glimepiride 1 2.7 Captopril 1 2.7 Amlodipine 2 5.4 Diamicrone 2 5.4 Herbal medicine 3 8.1 MST 7 18.9 Insulin 1 2.7 Crystal meth 2 5.4 Valsartan 1 2.7 History of smoking No Yes 10 27.1 Medical diagnoses 27 72.9 No cancer 3 8.1 Cancer 34 91.9 History of chemotherapy 3 8.1 No 34 91.9 Yes Table 1. shows that the majority aged were 36-46 majority repeated stoma was not 86.5%, majority history years 40.5%, majority gender were male 81.1%, majority of the disease was not 67.6%, majority history of using educational level were senior high school 54.1%, drugs were MST 18.9%, majority history of smoking majority religion was Muslim 54.1%, majority ethnicity was 72.9%, majority medical diagnose were cancer, and was Bataknese 59.5%, majority employment was farmer majority history of chemotherapy were 91.9%. 35.1%, majority history of stoma was 21 days to 6 months 37.8%, majority type of stoma were colostomy 94.6%, Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 505 Table 2. sexual dysfunction factors (n=37) Sexual dysfunction factors Frequency Percentage (%) Afraid of performance Unafraid 12 32.4 Afraid 25 67.6 Psychosexual trauma No 33 89.2 Yes 4 10.8 Inadequate counseling Adequate 16 43.2 Inadequate 21 56.8 Alcohol consumption No 17 45.9 Yes 20 54.1 Biological factors No 17 45.9 Yes 20 54.1 Sociocultural factors No 18 48.6 Yes 19 51.4 Table 2 showed that the majority of respondents were afraid of performance by 67.6%, the majority of respondents experienced psychosexual trauma by 10.8%, the majority of respondents did not get inadequate counseling of 56.8%, The majority of respondents consumed alcohol at 54.1%, the majority of respondents with biological factors were 54.1%, the majority of respondents with sociocultural factors were 51.4%. Table 3. incidence of sexual dysfunction in patients with stoma (n=37) Incidence of sexual dysfunction Frequency Percentage (%) No 11 29,7 Yes 26 70,3 Table 3 showed that the majority of sexual dysfunction incidences were 70.3 506 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Table 4. analysis of the relationship among risk factors affecting the occurrence of sexual dysfunction in patients with a stoma (n=37) Incidence of Sexual Dysfunction Total 95% CI Variable Function Dysfunction p-value RR f % f % n % Lower Upper Afraid of performance Unafraid 8 66.7 4 33.3 12 100% 0.00 14.66 2.67 80.41 Afraid 3 12 22 88 25 100% Psychosexual trauma No 9 27.3 24 72.7 33 100% 0.56 0.37 0.04 3.07 Yes 2 50 2 50 4 100% Inadequate counseling Adequate 10 62.5 6 37.5 16 100% 0.00 33.33 3.51 315.93 Inadequate 1 4.8 20 95.2 21 100% Alcohol consumption No 9 52.9 8 47.1 17 100% 0.01 10.12 1.77 57.91 Yes 2 10 18 90 20 100% Biological factors No 10 58.8 7 41.2 17 100% 0.00 27.14 2.91 252.63 Yes 1 5 19 95 20 100% Sociocultural factors No 8 44.4 10 55.6 18 100% 0.12 4.26 091 19.98 Yes 3 15.8 16 84.2 19 100% Table 5. factors that most influence the occurrence of sexual dysfunction in patients with a stoma 95% CI. for EXP.(B) Variable p-value Exp.(B) Lower Upper Inadequate counseling 0.034 20.84 1.25 347.47 Alcohol consumption 0.046 14.66 1.05 204.30 Biological factors 0.043 19.45 1.09 346.98 Constant -2,47 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 507 Table 5. showed that the strength of the relationship of not experiencing psychosexual trauma was 89.2%. seen from the Odds Ratio (OR) value, the variable that The results of the bivariate analysis showed that there most influences the incidence of sexual dysfunction in was no relationship between a history of psychosexual stoma patients is inadequate counseling with an OR trauma and the incidence of sexual dysfunction in stoma value of 20.84. The following is an interpretation of patients (p = 0.56). Although there is no association the OR value based on the Exp. (B) value: patients with between psychosexual trauma and the occurrence of stomas who do not receive inadequate counseling are at sexual dysfunction in patients with a stoma, sexual 21 times more likely to experience sexual dysfunction dysfunction can still occur, because victims who have than patients with stomas who receive an adequate experienced psychosexual trauma show a much higher education. rate of sexual function problems(14). Discussions Based on the results of the univariate analysis showed that the proportion of counseling was The results showed that the incidence of sexual inadequate at 56.8%. This is in line with Sutsunbuloglu dysfunction in patients with a stoma was 70.3%. and Vural, that patients who undergo stoma surgery Characteristics data on the majority of male sex must receive perioperative sexual counseling conducted experienced sexual dysfunction, namely 81.1%. This has by a multidisciplinary team including stoma nurses(8). something to do with the condition in which men tend to The results of this study are in line with the research close themselves in terms of expressing their desire for of Culha, Kosgeroglu, and Bolluk that only 6.5% of sexual desire to their partners. Patients with a stoma can patients received sexual education before and after experience sexual dissatisfaction and experience sexual stoma formation surgery(15). Based on the results of (8) dysfunction . the bivariate analysis, there was a relationship between The results showed that the proportion of fear inadequate counseling and the incidence of sexual of performance was 67.6%. Judging from the data dysfunction in patients with a stoma (p = 0.00). This on the characteristics of respondents, the majority of study is in line with research conducted by Zhu et al. that respondents’ ages were in the productive age range, there is a relationship between sexual life guidelines and (10) namely, the majority are 36-45 years old, namely 40.5%. the incidence of sexual dysfunction in stoma patients . This can be attributed to the fact that the productive age Based on the results of multivariate analysis, range tends to be more concerned with themselves and inadequate counseling was the factor with the greatest their appearance. This is in line with research conducted influence on the occurrence of sexual dysfunction in by Zhu et al. that ASEX scores in younger patients are patients with a stoma (p = 0.03; OR 20.84 95% CI 1.25- (10) significantly higher than in older patients . 347.47). Patients with inadequate counseling were 20.84 The results showed the relationship between fear times more likely to experience sexual dysfunction in of performance and the incidence of sexual dysfunction patients with stoma than patients who received adequate (p=0.00). According to Jayarajah and Samarasekera counseling. This has something to do with respondents’ stated that ostomy patients experienced much worse discomfort in discussing their sexual problems and they body image pressure than those without a history of feel embarrassed to initiate discussions with the health ostomy (p<0.001)(12). This study is in line with research team. This study is in line with the research of Zhu et conducted by Tseng et al. that 37% of patients with a al. stated that sexual life guidance is a factor that affects stoma reported that they often felt uncomfortable with the occurrence of sexual dysfunction in patients with a a colostomy because they felt that their body was stoma (p = 0.00; OR 16.78 95% CI 3.18-24.89). Patients incomplete, and was afraid that others would find out who did not receive sexual life guidance were 16.78 that they had a stoma. They were worried that the stoma times more likely to experience sexual dysfunction in bag would suddenly fall off(13). patients with stoma than patients who received sexual life guidance(10). In this study, it was found that there was a significant difference in the proportion of psychosexual The results showed a significant relationship trauma in stoma patients. The results of the univariate between the history of consuming alcohol and the analysis showed that the proportion of a history of incidence of sexual dysfunction in stoma patients (p = psychosexual trauma was 10.8%, while the proportion 0.01). The results of this study are in line with research 508 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 conducted by Rotinsulu, Turalaki & Rumbajan that out with the incidence of sexual dysfunction in patients with of 60 smoking drivers who consumed alcohol, it was a stoma (p = 0.04; OR = 19.45 95% CI = 1.09-346.98). found that 80% experienced erectile dysfunction with Patients who have biological factors have 19.45 times the highest degree of dysfunction in mild dysfunction, the risk of experiencing sexual dysfunction compared which was 45%. This shows that there is an effect of with patients who have no biological factors. The results alcohol consumption on erectile dysfunction in smoker of this study are in line with the results of research drivers with a value of p <0.05 or p = 0.001(16). conducted by Liao and Qin that patients with a stoma who have a chronic disease have a 13.93 times risk of The result of multivariate analysis of the history of experiencing sexual dysfunction compared to patients alcohol consumption is one of the variables that have without the chronic disease(18). a relationship with the incidence of sexual dysfunction in patients with a stoma (p = 0.04; OR = 14.66 CI = In this study, it was found that there was no significant 1.05-204.3). Patients who have a history of consuming difference in the proportion of socio-cultural factors in alcohol have a 14.66 times risk of experiencing sexual stoma patients. The results of the univariate analysis dysfunction in patients with stoma compared to patients showed that the proportion of sociocultural factors was who have no history of consuming alcohol. The results 51.4%, while the proportion of no sociocultural factors of this study are in line with the research of Rotinsulu, was 48.6%. The socio-cultural factor is everything Turalaki and Rumbajan (2016) that smokers drivers related to society and culture. Culture influences health who have a habit of drinking alcohol have 12 times the beliefs and health-related behavior because culture can chance of developing erectile dysfunction compared to affect health(19). smokers who do not drink alcohol(16). The results of the bivariate analysis showed that In this study, it was found that there was no there was no relationship between sociocultural factors significant difference in the proportion of biological and the incidence of sexual dysfunction in stoma patients factors in stoma patients. The results of the univariate (p = 0.12). This is not in line with research conducted by analysis showed that the proportion of biological factors Bhavsar & Bhugra that 75 Chinese people are influenced was 54.1%, while the proportion without biological by the traditional medical concept of yin and yang and factors was 45.9%. Data on the characteristics of Confucian thinking about sexual conservation. This respondents in this study were diabetes mellitus 13.5%, belief system strives to strike a balance between positive respondents with hypertension 18.9%, the majority and negative yin forces in the human body. Therefore, of respondents had a history of consuming drugs, many Chinese people think sexuality must be managed namely 54%, where the most consumed drugs were carefully so as not to damage their health(20). MST 18 drugs, 9%, the majority of respondents with cancer namely 91.9% and the majority of respondents Conclusions undergoing chemotherapy 91.9%. According to Costa Based on the results of the study, it can be concluded et al. diabetes, hypertension, and the use of sedatives that the prevalence of sexual dysfunction in patients with (17) are risk factors for sexual dysfunction . The results of a stoma is 70.3%. Some factors cause sexual dysfunction the bivariate analysis showed a significant relationship in patients with a stoma, namely fear of performance, between biological factors and the incidence of sexual psychosexual trauma, inadequate counseling, alcohol dysfunction in patients with a stoma (p = 0.00). The consumption, biological factors, and sociocultural results of this study are in line with research conducted factors. There is no relationship between psychosexual by Sutsunbuloglu and Vural that there is a relationship trauma and sociocultural factors on the occurrence of between chronic disease and the occurrence of sexual sexual dysfunction in patients with a stoma. There is )(8) dysfunction in stoma patients (p=0.01 . an association between fear of performance, inadequate The results of this study are in line with research counseling, alcohol consumption, and biological factors conducted by Sun et al. (2016) stated that there was a on the occurrence of sexual dysfunction in patients with significant relationship between receiving chemotherapy a stoma. The factor that most influences the occurrence and the occurrence of sexual dysfunction, namely p = of sexual dysfunction in patients with a stoma are 0.03. The result of multivariate analysis of biological inadequate counseling, where inadequate counseling factors is one of the variables that have a relationship has a risk of causing sexual dysfunction 20.84 times Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 509 compared to stoma patients who receive adequate Individuals: A Cross-Sectional Study from counseling. a Tertiary Care Center of Southern India. J Psychosexual Heal. 2019;1(3–4):257–61. Conflict of Interest: Nil 10. Zhu X, Chen Y, Tang X, Chen Y, Liu Y, Guo W, et Source of Funding: The study was initiated by the al. Sexual Experiences of Chinese Patients Living author and was not externally funded. with an Ostomy. J Wound, Ostomy Cont Nurs. 2017;44(5):469–74. Ethical Consideration: The Research Ethics 11. McGahuey CA, Gelenberg AJ, Laukes CA, Moreno Committee from the Commission of Health Research FA, Delgado PL, McKnight KM, et al. The Arizona Ethics Faculty of Nursing Universitas Sumatera Utara sexual experience scale (Asex): Reliability and No. 1751/IV/SP/2018 validity. J Sex Marital Ther. 2000;26(1):25–38. References 12. Jayarajah U, Samarasekera DN. Psychological adaptation to alteration of body image among stoma 1. Ozturk O, Yalcin BM, Unal M, Yildirim K, patients: A descriptive study. Indian J Psychol Med. Ozlem N. Sexual Dysfunction among Patients 2017;39(1):63–8. having undergone Colostomy and its Relationship 13. 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Psychosexual Dysfunctions Among alcohol-dependent 510 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13898 Biochemical Evidence of Overweight, Androgen Excess and Hyperinsulinaemia in Women with Polycystic Ovarian Syndrome in Nauth, Nnewi, Nigeria Nkiruka R Ukibe1, Charles T Chigbo1, Charles C Onyenekwe1, Adaobi A Chigbo1, Anya O Kalu2, Ejatuluchukwu Obi3, Ezinne G Ukibe2 1 Senior Lecturer, Post graduate, Senior Professor, Department of Medical Laboratory Science, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria. 2 Senior Lecturer, Medical Student, Department Medicine, Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria. 3 Associate Professor, Department of Pharmacology, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria Abstract Background: Polycystic ovarian syndrome (PCOS) is the most frequent androgen disorder of ovarian function. This was a cross-sectional study designed to evaluate the levels of sex hormone-binding globulin (SHBG), fasting insulin and some select androgens in women with polycystic ovarian syndrome (PCOS) in Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Nigeria. Materials and Methods: Seventy four (74) women aged between 18-40 years were conveniently selected. 37 of them attending the gynecological clinic were diagnosed with PCOS based on the Rotterdam criteria. The remaining 37 participants were apparently healthy hospital staff recruited as control. Blood sample was collected from all the participants for determination of SHBG, fasting insulin, testosterone, dehydroepiandrosterone sulfate (DHEA-S) and estradiol (E2) levels using standard laboratory methods. Results: Fasting insulin, testosterone, DHEA-S in participants with PCOS were significantly higher compared with their corresponding control participants (p = 0.005, 0.001, 0.001 respectively), while SHBG in participants with PCOS was significantly lower compared with the control participants (p = 0.002). Body mass index (BMI) and free androgen index ratio (FAI) were significantly higher in participants with PCOS compared with their corresponding controls (p = 0.043, 0.001). Waste/hip ratio showed a strong negative correlation with levels of SHBG and E2 in participants with PCOS (p = 0.025, 0.015, r = -0.368, 0.397 respectively), while BMI showed a strong negative correlation with E2 in participants with PCOS (r = -0.374, p = 0.023). Conclusion: Significantly higher BMI value shows evidence of obesity and or overweight infemale participants with PCOS. Significantly higher levels of testosterone, DHEA-S, fasting insulin, FAI, with lower SHBG suggests androgen excess and hyperinsulinemia which may subsequently predispose the women to type II diabetes. Keywords: Overweight, androgen excess, hyperinsulinaemia, women, polycystic ovary Introduction Corresponding author - Polycystic ovarian syndrome (PCOS) is the most Nkiruka R. Ukibe, frequent androgen disorder of ovarian function. It is the Senior Lecturer, Department of Medical Laboratory Science, most commonly encountered endocrinopathy in women College of Health Sciences, Nnamdi Azikiwe University, of reproductive age. It has significant reproductive and Nnewi Campus, Anambra State, Nigeria, E-mail address: nonreproductive consequences 1. Diagnostic criteria for [email protected] Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 511 PCOS mostly use the revised Rotterdam 2003 criteria between the ages of 18 and 40 years were included in 2. However, the etiology and pathophysiology of PCOS the study. Women outside the age bracket of 18 and remain unclear, and the multiple risk factors such as 40 years were excluded; women with metabolic and genetics, environment, nutrition, lifestyle, and much cardiovascular disorders, Pregnant and lactating mothers more are still under investigation. There is heterogeneity and women on contraceptive pills were also excluded of symptoms and in severity of disease but most have from the study. Data was collected through the use of central obesity or android fat deposition (fat at abdominal questionnaires, anthropometric measurements and wall and viscera). Android fat deposition is relatively biochemical analysis of blood samples. Ultrasound was resistant to insulin hormone 3. According to 4central also done to obtain ovarian morphology. obesity is diagnosed when waist circumference is more Anthropometric measurements than 80 centimeters for women. However, women of any ethnic background can present with PCOS. Both of The Physical measurements (body weight and central obesity and androgen excess in PCOS accelerates height) was taken using a standard beam balance scale insulin resistance which promotes incidence of diabetes and a stadiometer respectively, participants were advised 5 mellitus . Hyperinsulinemia with insulin resistance is to wear light clothing with no shoes for an accurate believed to be highly associated the symptoms of PCOS measurement, values obtained was used to calculate including anovulatory, infertility and hyperandrogenism BMI (kg/m2) [weight (kg)/(height)2 (m2)]. Blood and these symptoms can be reversed by reducing the pressure (systolic and diastolic) was also measured 6 hyperinsulinaemia . This study therefore, was designed using standard clinical mercury sphygmomanometer to to investigate some biochemical evidence of overweight, rule out any cardiovascular disorder. androgen excess and hyperinsulinaemia in women with PCOS in Nnewi, Nigeria. Collection of blood samples Materials and Methods About 5ml of fasting venous blood was collected aseptically from each participant by venopuncture This was a cross sectional study, a total of seventy technique from the cubital fossa and dispensed into four (74) women within the ages of 18 and 40 years properly labeled plain containers. The samples were were recruited at the Gynecology Clinic, Nnamdi allowed to clot and centrifuged at 4,000 rpm for 10 Azikiwe University Teaching Hospital Nnewi, Anambra minutes. The serum was extracted and transferred into State, Nigeria, using convenient sampling technique. properly labeled tubes and stored at -20oc. They include thirty seven (37) women with mean age (29.00±6.0) attending the Gynecology Clinic at Laboratory methods the Nnamdi Azikiwe University Teaching Hospital, The reagents were commercially obtained and the Nnewi, Nigeria in whom ultrasound and clinical standard operating procedures were strictly adhered to diagnosis of PCOS have been established and based on base on manufacturer’s instructions. All the parameters Rotterdam criteria. This criterion states that for PCOS were determined using Enzyme-linked immunosorbent to be established, two out of the following three criteria assay (ELISA) methods. must be present: (i) Oligo- and/ or anovulation, (ii) hyperandrogenism (clinical and/or biochemical) and (iii) Sex hormone-binding globulin (SHBG) polycystic ovaries. Thirty seven (37) apparently healthy was done as described by Ly and Handelsman 7. women recruited among the staff served as control. A Testosterone was done as described by Ganie et al, 8. well structured questionnaire was used to ascertain the Dehydroepiandrosterone-sulfate (DHEA-S) was done as reproductive history and biodata of the participants. All described by Elmlinger et al 9 and Estradiol as described the participants were all in Nnewi metropolis. by Liu et al 10. Determination of Fasting insulin level was done as described by Jolanta et al 11, while FAI was Inclusion and Exclusion criteria calculated by the use of the equation, 100 × T/SHBG. Women with evidence of anovulation, hyperandrogenism and polycystic ovaries who are 512 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Statistical analysis Levels of steroid hormones in participants with PCOS and control group The collected data was analyzed using the Student’s t-test and mann-Whitney test. Values were The mean serum SHBG (ng/ml) level in participants deemed statistically significant if p value ≤ 0.05, Pearson with PCOS (1.69±4.29) was significantly lower compared correlation coefficient was used for correlation of the with control participants (4.54±3.08) (P = 0.002). On the parameters. contrary, the mean serum testosterone (ng/dl), DHEA-S (µg/dl), levels in participants with PCOS (107.43±28.08, Results 243.97±96.04) were significantly higher compared with Levels of some anthropometric parameters in control participants (35.46±17.69, 127.03±47.54) (P = participants with PCOS and control group 0.001, 0.001 respectively). However, the mean E2 (mlU/ ml) level was not significantly different between PCOS The mean values of age (years), waist circumference and control participants (107.08±98.26) (P = 0.507) (cm), hip circumference (cm), waist/hip ratio (cm), (Table 2). systolic blood pressure (mmmHg), diastolic blood pressure (mmHg) and BMI (kg/m2) in participants with Correlation of waist/hip ratio, BMI, SHBG and PCOS were (29.00±6.00, 84.27±15.74, 100.03±17.08, Estradiol in participants with PCOS 0.84±0.06, 110.27±9.35, 74.32±7.65, 26.70±4.61) Waist hip ratio was negatively correlated with SHBG compared with control participants (28.43±4.20, and estradiol in participants with PCOS (r = -0.368, 80.65±9.49, 98.35±8.32, 0.82±0.07, 108.11±8.45, -0.397) (P = 0.025, 0.015) respectively. Similarly, 72.84±8.21, 24.77±3.35) (P = 0.100, 0.234, 0.593, there was a strong negative correlation between BMI 0.120, 0.300, 0.423, 0.043) respectively, only BMI and estradiol in participants with PCOS (r = -.374, P = was significant higher in PCOS women compared with 0.023) (Table 3). controls (Table 1). Table 1. Levels of some anthropometric parameters in participants with PCOS and control group Parameters PCOS Control group T-test P-value Age 29.00±6.00 28.00±4.20 1.800 0.100 Waist circumference (cm) 84.27±15.74 28.00±4.20 1.199 0.234 Hip circumference (cm) 100.03±17.08 98.35±8.32 0.537 0.593 WHR 0.84±0.06 0.82±0.07 1.574 0.120 BMI (kg/m2) 26.70±4.61 24.77±3.35 2.059 0.043* SBP (mmHg) 110.27±9.35 108.11±8.45 1.044 0.300 DBP (mmHg) 74.32±7.65 72.84±8.21 0.806 0.423 Key: WHR- Waist/Hip Ratio, DBP- Diastolic Blood Pressure, BMI- Body Mass Index PCOS- Polycystic Ovarian Syndrome, SBP- Systolic Blood Pressure Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 513 Table 2. Levels of steroid hormones in participants with PCOS and control group Parameters PCOS control group T-test p-value SHBG (ng/ml) 1.69±4.29 4.54±3.08 -3.283 .002* Testosterone (ng/dl) 107.43±28.08 35.46±17.69 13.193 0.001* DHEAS (µg/dl) 243.97±96.04 127.03±47.54 6.638 0.001* E2 (mlU/ml) 91.52±102.37 107.08±98.26 -0.667 0. .507 Insulin (mlU/l) 6.31±3.51 4.51±1.01 3.001 0.005* FAI 153.10±85.19 18.91±26.53 9.148 0.001* Key: SHBG - Sex Hormone-Binding Globulin, DHEA-S- Dehydroepiandrosterone Sulphate E2-Estradiol Table 3. Correlation of waist/hip ratio, BMI, SHBG and E2 in participants with PCOS (n=37). Parameter r p-value WHR vs SHBG -0.368 0.025* WHR vs E2 -0.397 0.015* BMI vs E2 -0.374 0.023* Key: WHR- Waist/hip ratio, BMI-Body mass index, SHBG- Sex Hormone-Binding Globulin E2- Estradiol, r- Pearson Correlation Co-efficient. Discussion The higher incidence of overweight observed in this study may be attributed to the food habits adopted Polycystic ovary syndrome (PCOS) is a common and lack of exercise among the participants. This cause of ovarian dysfunction in women of childbearing is consistent with previous studies 13. Markopoulos age. Among the most frequent symptoms of PCOS are reported that approximately half of women with PCOS anovulation, infertility and hyperandrogenamia which are obese or overweight and obesity plays an important is produced by the presence of Hyperinsulinemia with role in the development of hyperandrogenic state in constant occurrence of insulin resistance in the affected PCOS individuals. Lack of exercise and inadequate 6 individuals . This study was carried out on women with fiber intake has been highly implicated in the onset and PCOS who are at their peak reproductive age of 18 - development overweight in young females in Nigeria 13, 40 years. In this study, majority of the women who had and this could subsequently result to variation in steroid PCOS were within the age group of 20-31 years, with hormones hence, PCOS 14. Several women with PCOS mean age of 29.00±6.00 years. This is in line with the become overweight just before or during puberty and this work done by Igwegbe et al, 12 514 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 could lead to onset of obesity in this period of life which The mean DHEA-S level was also significantly may further develop to PCOS 15. It has been shown that higher in participants with PCOS compared with control more than 5-10% weight loss improves fertility and participants. This could be attributed to increased body menstrual cycles in women with PCOS 16. Adam and weight including ovarian and adrenal dysfunction. The Edmonds, 17 also reported that improvement in lifestyle main source of androgen in women with PCOS is the with a combination of exercise and diet to achieve ovary 5. Another study by Christodoulaki et al, 28 also weight reduction is important to enhance the prospects reported a mildly increase in DHEA-S level in women of both spontaneous and drug induced ovulation. with PCOS. It has been however, documented that peripheral testosterone, androstenedione and DHEAS The significantly lower SHBG level in participants levels were significantly reduced by weight loss in obese with PCOS could be as a result of increase testosterone women with PCOS 5. This therefore, confirms the role and or excess body weight. Increased body weight has of obesity in the development of hyperandrogenism been significantly implicated in the variation of clinical observed in women with PCOS. Similarly, it shows that and hormonal presentation of PCOS 5. Moran et al., 18 weight loss increases the SHBG levels, and significantly has attributed the cause of PCOS to increased GnRH modified the clearance rate of testosterone and its free frequently due to hyperinsulinemia leading to reduction fraction in obese PCOS women 23. This further confirms in SHBG level. There are often low levels of sex the effect of weight loss in the reversal of most of the hormone-binding globulin in particular among obese or possible risk factors that may predisposes women to overweight women 19. Martinez-Garcia and colleagues androgen excess with subsequently development of reported reduced serum SHBG level, which regulates the polycystic ovary syndrome. bioavailability of androgens to target tissues resulting in high levels of androgens in PCOS patients 20. SHBG This study also showed that the mean level of insulin has been shown to be inversely correlated with body in participants with PCOS was significantly higher mass index in both premenopausal and post-menopausal compared with control participants. This may result obese women 21. However, it has also been established from excess body weight as was observed in this study that other factors such as diet, body fat distribution and and may predispose the affected individual to type II insulin could be responsible for metabolic regulation of diabetes. The observation was similar to the earlier study SHBG thereby; increasing free androgen levels in PCOS by Richard 29. The author reported that women with patients 22. Furthermore, the decreased SHBG has been PCOS have increased prevalence of insulin resistance also reported to increase the metabolic clearance rate of and type II diabetes, even when controlling for body mass circulating SHBG-bound steroids 23. index (BMI). Nafiye et al, 30 also reported that serum insulin and insulin resistance are higher in participants The mean level of testosterone in participants with with PCOS. Insulin has shown to be an important PCOS was significantly higher compared with control indicator in the regulation of ovarian steroidogenesis 31. participants. This could be attributed to inadequate fiber Higher level of serum insulin was reported as a possible intakes, ovarian or adrenal dysfunction 24. Earlier study cause of increase incidence of hyperandrogenism and by Teede et al., 25 also reported increased serum androgen reduced SHBG in women with PCOS 23. Furthermore, levels including testosterone and androstenedione in increased production of endogenous androgens in participants with PCOS. Previous study similarly, women by insulin could be through regulation of SHBG revealed that the concentration of testosterone are synthesis and metabolism 32. Insulin has been involved higher in some obese than non-obese women with in the inhibition of SHBG thereby, acting as a potent PCOS 26. FAI of the ratio of testosterone to SHBG was regulator of SHBG concentrations invivo 33. An inverse also significantly high in this study. It has however, correlation between insulin and SHBG concentration has documented that about half the total testosterone is been reported in both pre and postmenopausal women tightly bound to SHBG while the other half to albumin, 34. Waist/hip ratio was also shown to be negatively causing reduction in SHBG and increasing the free correlated with SHBG and estradiol in participants with testosterone level in PCOS patients 27. PCOS. This was in line with the previous finding by Sieminska et al, 35. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 515 Conclusion 2012; 20(5): 1012–5. doi: 10.1038/oby.2011.375 Findings from this study have shown significant 5. Bulun SE. Physiology and Pathology of the Female Reproductive Axis. Williams Textbook of evidence of overweight and hyperadrogenaemia Endocrinology (Thirteenth Edition), 2016. (androgen excess) with hyperinsulinamia in women with PCOS. This might subsequently predispose the affected 6. Chen C, Smothers JC, Lange A, Nestler J, Strauss women to type 11 diabetes mellitus and subsequent III JF et al. Sex Hormone-Binding Globulin Genetic Variation: Associations with Type 2 Diabetes cardiovascular diseases if not adequately managed. Mellitus and Polycystic Ovary Syndrome. Minerva Early identification of patients at risk and prompt Endocrinol. 2010; 35(4): 271–80. initiation of therapies is strictly advocated by including 7. Christodoulaki C, Trakakis E, Pergialiotis V routine analysis of select androgens and fasting insulin et al. Dehydroepiandrosterone-Sulfate, Insulin in fertility clinics. 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Brodowska A , Wiśniewska B , Kotlega D, DOI Number: 10.37506/ijphrd.v12i1.13899 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 517 Prevalence and Pattern of Musculoskeletal Problem among Software Engineers in a Private Firm, Chennai- A Cross Sectional Study Jasmine M 1, Ravivarman G 2, Vinoth Gnana Chellaiyan3, Buvnesh Kumar3 1Postgraduate, Department of Community Medicine, Chettinad Hospital and Research Institute (Chettinad Academy of Research and Education), Kelambakkam, Tamil Nadu, 2 Professor, Department of Community Medicine, Chettinad Hospital and Research Institute (Chettinad Academy of Research and Education), Kelambakkam, Tamil Nadu, 3Assistant Profeesor, Department of Community Medicine, Chettinad Hospital and Research Institute (Chettinad Academy of Research and Education), Kelambakkam, Tamil Nadu Abstract Introduction: Information Technology Industries has been a boon to many jobseekers. With its advantage, it has also brought many disadvantages in view of the health of the Software Engineers. Objectives: The objectives of the present study were to estimate the prevalence and pattern of musculoskeletal problems among the Software Engineers Material and Methods: This study was a cross sectional study conducted among Software Engineers working in a private firm Chennai. The sample size was calculated to be 403. The study was conducted with the nordic questionnaire. The data was collected and analysed through Statistical Package for Social Sciences. Multivariate analysis, Chi square was calculated and P value of less than 0.05 was considered significant. Results: The results showed that the median age of participants was 26 years. The overall prevalence of musculoskeletal problem in any area of focus was 85.6% in the past 1 year and 49.9% in the past 1 week. The majority was affected with problems in the Neck followed by the Lower back and Shoulders. Keywords: Musculoskeletal problem, Software Engineers, Inofrmation Technology Introduction are caused or intensified by work” is called as the Work- related musculoskeletal disorders.1 The main risk factors Musculoskeletal problem remains one of the main for the development of these disorders are high intensity causes of Sickness Absenteeism. There are many stress, postural demands, long-term muscular strain etc.1 work-related and non-work-related determinants of musculoskeletal problem among the occupational group. These issues are reported more in those who uses WHO defines work related musculoskeletal disorders computers every day during their work. Software (WRMSDs) as “The musculoskeletal disorders which Engineers experience strong postural demands, repetitive stress, static muscular load etc, which contributes to the Corresponding Author: development of Musculoskeletal disorders among them. Dr. Vinoth Gnana Chellaiyan Among many causes which attributes to the Assistant Profeesor, Department of Community Medicine, Chettinad Hospital and Research Institute, development of work-related musculoskeletal disorders, Chettinad Academy of Research and Education, workstyle plays a very crucial part. The hazardous Kelambakkam, Tamil Nadu, Phone: 9944894554 workstyle with respect to the computer work is also 2 Email; [email protected] called as “Maladaptive coping behaviours.” The 518 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 interaction between the risk factors like psychosocial Sampling method: and ergonomic, play a vital role in the development of The sampling method used was simple random disorders in the locomotor system and limiting their sampling done in 2 phases. ability. 3,4 Along with these, the time constraint work and increased work demand give an added disadvantage Phase 1: Selection of a private IT firm: to the development of WRMSDs CMMI (Capability Maturity Model Integration) 6,7,8 The objective of this study was to estimate the is an appraisal given to the companies by the CMMI prevalence and pattern of musculoskeletal problems Institute, a subsidiary of Information Systems Audit among the Software Engineers working in a private firm, and Control Association. In CMMI there are 5 levels, Chennai. with 5 being the highest in order. The levels define the activities the firms undertake and defines the capability Methodology of the organisation. The level 1 firm is ad-hoc while Study design and setting: the highest-level firms have specific guidelines (like legibility and ergonomics) of their own. These types of This study was a cross sectional study conducted organisations deal with more complex projects. The work in a private Information Technology firm in Chennai, targets of the employees are time bound. The employees Tamil Nadu, India compromise the work style, ergonomic principles and Study Population: longer duration of computer usage etc. Thus level 5 firm was chosen for the study. The study was conducted among the Software Engineers working in a private firm, Chennai. There were totally sixteen CMMI level 5 firms in Chennai 9, Tamil Nadu and out of that one company was Inclusion criteria: selected by simple random method using Lottery method i) Software engineers who had an experience of Phase 2: Selection of the participants: more than 2 years in the same company There were totally 12800 Software Engineers ii) Software Engineers with the age less than 40 working in the selected company and out of which, years, both genders 4580 software engineers fulfilled the inclusion criteria among which 33 of them were excluded on the basis Exclusion criteria: of exclusion criteria. The name listing of the remaining i) Software engineers who had past history of 4547 employers in the alphabetical order was done and spine surgery or spinal disease such as disc prolapse, random number was allotted to them. Then the sample of discitis etc. 403 was selected by computer allotted random number table. ii) History of arthritis such as rheumatoid arthritis, osteoarthritis, psoriatic arthritis etc Study instrument: iii) Orthopedically physically challenged and A standardised pre-tested semi structured Pregnant women. questionnaire was used. It had 2 sections. Section 1 consists of demographic profile and section 2 was nordic Sample size determination: questionnaire. The prevalence of musculoskeletal disorder among Section 1: the software professionals was reported as 64.5%. 5 in a previous study and allowable error of 5%, the sample This section included the basic details of the size was calculated to be 366.36 using the formula 4pq/ participants like age, gender, years of experience and the l2. Accounting for the non-response rate of 10%, the duration of computer usage. This section also includes final sample size arrived was 403. anthropometric measurements like weight and height. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 519 Section 2: Statistical Analysis Nordic Questionnaire 10: Data was entered in Microsoft Excel Spread Sheet and analysed in Statistical Package for Social Sciences This section had questions about the area of the body (SPSS- IBM) software version 21. Data was assessed with the musculoskeletal symptoms in the past one week for normality before applying tests of significance. and one year. The areas specified are neck, shoulders, Chi square test was applied. P<0.05 was considered upper back, elbows, wrists/ hands, lower back, hips/ significant. Association between the variables is analysed thighs, knees and ankles/ feet. by calculating odds ratio. Data collection procedure: Results After obtaining written informed consent, The median age of the study participants were 26 the participants were interviewed using pre tested years. 51.4% were in the age group of 23-26 years. questionnaire. Confidentiality of the study participants Among the 403 participants, 61.5% were males. 47.1% was maintained in all phases of the study. had work experience between 2 and 4 years in software firm. Almost all the study participants (96%) had more than 5 hours of computer usage in a day. Table 1: Profile of study participants (N=403) S no Profile Frequency Percentage Age (years) 1. < 30 355 88.1 >30 48 11.9 Gender 2. Male 248 61.5 Female 155 38.5 Work experience (Years) 4 <6 304 75.4 >6 99 24.6 Total duration of computer usage in a typical day (Hours) 5 <7 83 20.6 >7 320 79.4 Total duration of continuous computer usage without break in a typical day 6 (Hours) <1 77 19.1 >1 326 80.9 Maximum study participants (85.6%) had musculoskeletal problem in the past 1 year and 49.9% had it in the past 1 week. (Table 2) 520 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Table 2: Distribution of study participants according to the prevalence of any musculoskeletal problems (N= 403) S no Variable Frequency Percentage Musculoskeletal problems in the past 1 week 1 Yes 201 49.9 No 202 50.1 Musculoskeletal problems in the past 1 year 2 Yes 345 85.6 No 58 14.4 Inability in performing daily activities in the past 1 year 3 Yes 148 36.7 No 255 63.3 Medical consultation in the past 1 year 4 Yes 84 20.8 No 319 79.2 Maximum number of study participants had musculoskeletal problem in neck (56.1%), followed by lower back (53.8%) and wrist/hands (49.4%). Table 3: Pattern of Musculoskeletal problem among the software engineers in the past 1 year (N= 403). Musculoskeletal problem Musculoskeletal problem that Musculoskeletal problem Area causing disability needed medical consultation N (%) N (%) N (%) Neck 226(56.1) 57 (14.1) 32(7.9) Lower Back 217(53.8) 88 (21.8) 39(9.7) Wrist/Hand 199(49.4) 41 (10.2) 11(2.7) Shoulder 170(42.2) 48 (11.9) 18(4.5) Ankle/Feet 163(40.4) 46 (11.4) 26 (6.5) Hip/Thigh 162(40.2) 49 (12.1) 14 (3.5) Upper Back 136(33.7) 47 (11.7) 18 (4.5) Knee 89(22.1) 33 (8.2) 15 (3.7) Elbow 64(15.9) 13 (3.2) 1 (0.2) *multiple options applicable Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 521 Among those who work for more than 7 hours in computer per day, 87.5 % developed musculoskeletal problem (p value=0.034). Similarly among those who work continuously for more than 1 hour in computer without a break, 86.5% developed musculoskeletal problem. (Table 4) Table 4: Distribution of Musculoskeletal problem according to the profile of the participants (N= 403). Musculoskeletal problem S no Variable Odds ratio (CI) P value Yes (%) No (%) Age (years) 1 < 30 303 52 0.832 (0.337-2.057) >30 42 6 0.691 Gender 2 Male 205 43 0.511 (0.273-0.955) Female 140 15 0.033 Computer Usage in a day (Hours) 3 <7 65 18 >7 0.516 (0.278-0.957) 280 40 0.034 Continuous Computer Usage without Break in a typical day 4 (Hours) <1 63 14 0.702 (0.363-1.359) >1 282 44 0.292 Discussion participant was 65.4%. In the present study the median age of the The present study showed that the majority of the participants was 26 years. This coincides with the study participants (79.4%) had duration of computer usage for done by Bhanderi D et al 11, in which the mean age of more than 7 hours per day. A study done by Talwar R the participant was 25.04 years. In the present study, the et al 14 showed that 66% spent more than 6 hours per majority of the study participants were in the age group day in computer. The present study also observed that of 23-26 years. Similarly, in a study done by Das R 12, among those who used computer for 5 to 7 hours, 79.1% the mean age of the participant was 29 years and, in a developed musculoskeletal symptoms Similarly, a study study, conducted by Shrivastava SR et al 13, the majority done by Shrivastava SR et al 13 showed that among those of the study population was in the age group of 20-39 who used computer for 6 to 8 hours, 66.6% developed years. the symptoms. In the present study, the majority of the study The present study stated that 85.6% of the sample population were males (61.5%). This coincides with the had musculoskeletal problem in the last 1 year. In study done by Bhanderi D et al 11, in which the male a study done by Sharma AK et al 15 detailed that the 522 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 prevalence of musculoskeletal problem is around 77.5% short form of the Workstyle measure. Occupational and in the same way Talwar R et al 14 conducted a study, medicine. 2005 Dec 15;56(2):94-9. which showed that the musculoskeletal prevalence 5. Kausalya R, Amuthalakshmi P. Relationship was 76.5%. The slightly lower prevalence in this study between Ergonomic factors and health hazards in could be attributed to non-homogeneous workstation Software Industries (A study conducted at Chennai, environment, level of knowledge and practice between India). Journal of Environmental Researh And the studies etc. Development Vol. 2007 Oct;2(2). 6. Tarcsi Á. Using the CMMI Model to Determine Limitation: the Quality of a Web Project. InProceedings- Similar studies focussing on software engineers 5th International Conference on Management, Enterprise and Benchmarking (MEB 2007) 2007 working in different levels with different work pattern (pp. 193-200). Óbuda University, Keleti Faculty of could yield better understanding of the disease burden. Business and Management. Conclusion 7. Team CP. CMMI for Systems Engineering/ Software Engineering/Integrated Product and The musculoskeletal problems can decrease the Process Development/Supplier Sourcing, Version efficiency of the Software Engineers and thereby decrease 1.1, Continuous Representation. CMU/SEI. 2002 the productivity. Frequent workshops highlighting Mar. the preventive strategies should be conducted by the 8. Sinclair MA. Ergonomics issues in future systems. organisations. The Engineers should be trained about Ergonomics. 2007 Dec 1;50(12):1957-86. the coping strategies such as periodic health check-up, 9. Published Appraisal Results [Internet]. Sas. healthy life styles and adequate breaks between the cmmiinstitute.com. 2016 [cited 19 October 2016]. computer usage. Available from: https://sas.cmmiinstitute.com/ pars/pars.aspx Conflict of Interest: Nil 10. Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Source of Funding: Self Biering-Sørensen F, Andersson G, Jørgensen K. Standardised Nordic questionnaires for the analysis Ethical Clearance: Institutional human ethics of musculoskeletal symptoms. Applied ergonomics. committee, Chettinad Hospital and Research Institute 1987 Sep 1;18(3):233-7. References 11. Bhanderi D, Choudhary SK, Parmar L, Doshi V. Influence of psychosocial workplace factors 1. Preventing Musculoskeletal Disorders in on occurrence of musculoskeletal discomfort in WorkPlace [Internet]. Who.int. 2003 [cited 15 computer operators. Indian Journal of Community October 2018]. Available from: http://www.who. Medicine. 2007 Jul 1;32(3):225 int/occupational_health/publications/en/oehmsd3. 12. Das R. Occupational Health Concerns of Software pdf Professionals and Their Coping Strategies. 2. Griffiths KL, Mackey MG, Adamson BJ. The International Journal of Research Business impact of a computerized work environment on Strategy. 2012 Oct;1(1). professional occupational groups and behavioural 13. Shrivastava SR, Bobhate PS. Computer related and physiological risk factors for musculoskeletal health problems among software professionals in symptoms: a literature review. Journal of Mumbai: A cross-sectional study. International occupational rehabilitation. 2007 Dec 1;17(4):743- Journal of Health & Allied Sciences. 2012 Apr 65. 1;1(2):74. 3. Feuerstein M, Huang GD, Pransky G. Workstyle 14. Talwar R, Kapoor R, Puri K, Bansal K, Singh S. A and work-related upper extremity disorders. study of visual and musculoskeletal health disorders Psychosocial factors in pain. New York: Guilford. among computer professionals in NCR Delhi. 1999:175-92. Indian journal of community medicine: official 4. Feuerstein M, Nicholas RA. Development of a publication of Indian Association of Preventive & Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 523 Social Medicine. 2009 Oct;34(4):326. technology professionals in Delhi. Indian journal 15. Sharma AK, Khera S, Khandekar J. Computer of community medicine. 2006 Jan 1;31(1):36. related health problems among information 524 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13900 The Prevention Program of Cervical Cancer in Public Health Settings: A Review Anggi Lukman Wicaksana,1,2, Nuzul Sri Hertanti3 1Assistant Professor, Department of Medical Surgical Nursing, Universitas Gadjah Mada (UGM), Indonesia, 2Researcher, The Sleman Health and Demographic Surveillance System, UGM, Indonesia, 3Researcher, Center for Tropical Medicine, UGM, Indonesia Abstract This paper aimed to describe the World Health Organization (WHO) recommendation regarding cervical cancer prevention program and its implementation in public health settings of Indonesia. Human papillomavirus (HPV) vaccination, healthy sexuality education, and male circumcision belong to primary prevention. In Indonesia, the target of HPV vaccination coverage was assumed to be 76.6% among girls in the elementary school. Secondary prevention consisted of screening and treatment pre-cancer. Pap smear and Visual Inspection with Acetic Acid (VIA) were the national program to detect cervical cancer in Indonesia. Tertiary prevention included treatment and palliative care. Hospital had responsibility to treat advanced cancer patients, while the implementation of palliative care in public health center (PHC) in Indonesia is still limited. In the future, it is important for each country to develop a national policy regarding cervical cancer prevention in accordance with the WHO framework. Keywords: cervical cancer, Indonesia, prevention, public health Introduction In order to overcome the increasing of cervical cancer case, WHO issued some recommendation Cervical cancer is the fourth most common women’s programs focused on primary, secondary, and tertiary cancer in the world1. Globally, an estimated 528,000 new prevention6. WHO suggests all of the countries could be cases of this disease were diagnosed in 20122. About able to implement the prevention program for cervical 85% of the total cases occurred in developing countries3. cancer. Indonesia, as one of the low-and-middle-income HPV, the most common reproductive tract virus, was countries adopted the WHO recommended program reported as the leading cause of cervical cancer1. regarding cervical cancer prevention. To date, this paper The progression of cervical cancer leads around reviewed the WHO recommended programs of cervical 266,000 deaths among women worldwide3. The HPV cancer prevention and its implementation in public 16 and 18 caused a total of 70% cervical cancer cases health settings in Indonesia. worldwide. In Indonesia, approximately 20,928 new cases of cervical cancer were diagnosed and this disease Methods as the second rank of women’s cancer every year and This is a review of literature. We applied systematic around 9,498 Indonesian women died due to cervical search using “cervical cancer” AND “prevention cancer5. program” in PubMed, Science Direct, and Google Scholar databases. Authors also conducted handwriting search in WHO, HPV, and Indonesian report on cervical Corresponding author: cancer. All studies were included till January 2018. The Nuzul S. Hertanti, findings were summarized using narrative approach to Gd. Libang 2F UGM Jl. Medika, Yogyakarta, deliver the main message of cervical cancer prevention. Indonesia 55281. E-mail: [email protected] Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 525 Results and Discussion recommended as a priority particularly in the resource- constrained settings. The first priority of the HPV Cervical Cancer Prevention Program vaccination should be applied to young females4. The prevention and control programs for cervical Both of two licensed HPV vaccines have been cancer have been applied through universal access evaluated for the safety. Both of them are well tolerated to sexual and reproductive health services in the and have been administered more than 175 million doses Millennium Development Goals6. Currently, WHO worldwide. In the US, the most common of complaints includes cervical cancer prevention and control programs from vaccinated girls was pain and swelling at the injected as part of priority actions in the global action plan for site. The other reports of adverse reactions after HPV the prevention and control of NCDs 2013-2020. The vaccinations were fever, dizziness, and nausea. Serious cervical cancer prevention and control program aims adverse events were rarely reported. If any anaphylaxis to prevent and reduce the morbidity and mortality of symptoms were detected, the health professionals will cervical cancer. It has three core components: primary, immediately treat as needed3. secondary, and tertiary prevention3. The vaccine should not be administered to people Primary Prevention who have experienced a severe allergic reaction after Globally, primary prevention of cervical cancer- the first dose of vaccine and girls or women with severe focused on reducing the HPV infection. The primary febrile illness. The symptoms of an allergic reaction prevention program of WHO recommendation includes include itching, rash, or blisters on site of vaccine HPV vaccinations, healthy sexuality education, and injection. In addition, the pregnant women are not male circumcision3. recommended to obtain HPV vaccination3. HPV Vaccination. WHO recommended HPV In order to implement the HPV vaccination, WHO vaccination as integrated part of national immunization recommends strategies to deliver HPV vaccine in health programs because the vaccine could prevent cervical care facilities and deliver through outreach particularly cancer and other HPV-related diseases. However, HPV school-based delivery to reach girls aged 9-14 years. vaccination could not eliminate the need for cervical for females 15 years and above, the delivery could be cancer screening later in life3. Currently, WHO licensed held in the community3. In the school, teachers have a HPV vaccine including bivalent and quadrivalent responsibility to educate students and parents, assist the vaccine. The bivalent vaccine protects against HPV vaccine delivery team to ensure the eligible girls, and 16 and 18. While, the quadrivalent vaccine protects facilitate any logistical issues. Moreover, the health from HPV 6, 11, 16, and 18. HPV vaccination is more professionals will manage and deliver the HPV vaccine3. effective when administered prior to people involved in The implementation of HPV vaccination is still sexual intercourse4. being a pilot program since 2016 in Indonesia. The pilot WHO recommends administering HPV vaccine program obtained funding support from Global Alliances among girls aged 9-14 years because the vaccination for Vaccine and Immunization (GAVI)7. The Ministry of could be a primary prevention intervention prior to Health (MoH) in Indonesia did the pilot program of HPV the onset of sexual activity. For these populations, the vaccination in some schools in Jakarta and Yogyakarta. girls could obtain a two-dose schedule with interval The targets of vaccination are girls at the 5th and 6th from 6 to 12 months after the first administration. For grade of elementary school8. The MoH already has girls with immunocompromised conditions (e.g. HIV, engaged the PHC to visit schools and did the vaccination lupus erythematous, etc.) and females ≥ 15 years should in schools9. When the HPV vaccination applied among receive three doses of HPV vaccine. The second doses girls studying at a 5th and 6th grade of elementary of vaccination should take 1 to 2 months after the first schools, no extremely side effects of the vaccine. All of dose. While, the third doses should be administered 6 the schools reported students felt pain after HPV vaccine months after the first dose3. Moreover, WHO considers injection and it appeared in 24 hours9. According to the HPV vaccination among males. However, it is not Ministry of Women and Child Empowerment, the target 526 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 of vaccination coverage is assumed to be 76.6% among Pediatrics, and the US Centers for Disease Control and girls in the elementary school in Indonesia10. Prevention issued affirmative policy recommendation for women to choose a circumcised sexual partner or Healthy Sexuality Education. WHO recommends encourage an uncircumcised partner to get circumcised the healthy sexuality education is conducted as and women could decide the choice of male circumcision appropriate to age and culture. The sexuality education for their sons ideally soon after birth as well as for includes delaying the first intercourse, reducing the their brothers and other male family members16,17. In high-risk of sexual behaviors such as reducing sexual Indonesia, male circumcision is the cultural and religious partner, using condom for those who are sexually active, issue among Muslims. Therefore, the male circumcision sexual negotiation skills such as how to assertive in coverage in Indonesia is achieving 100% in Indonesia4. communication to refuse premature intercourse, and contraceptive choices11. Secondary Prevention Indonesia established the healthy sexuality WHO determined the secondary prevention of education program in particular for the adolescents. cervical cancer including screening and treatment pre- The Indonesian government including the MoH and cancer6. In cervical cancer, screening aimed to ensure National Population and Family Planning Broad appropriate treatment or management population with (Badan Kependudukan dan Keluarga Berencana a positive or abnormal result. Additionally, screening Nasional-BKKBN) were collaborated to deliver healthy can potentially detect cervical cancer among women sexuality education integrated with the contraception at an early stage. Health professionals could provide and reproductive program. The educators could be pre-cancer treatment for women with a positive result health professionals in PHC and or the adolescents who cervical cancer-screening test. The purpose of pre- already obtained training. The Indonesian government cancer treatment is to destroy or remove the area of has a program for adolescent called “Generation cervix detected as pre-cancer3. Planning (Generasi Berencana/GenRe)” since 2010. The Screening Test for Cervical Cancer. It is program aims to reduce the unhealthy sexual behavior recommended to do screening at least once in a lifetime among adolescent through education program regarding among women with 30 to 49 year-old. However, the reproduction health, drugs abuse, HIV/AIDS, the decision about the target age and frequency of screening maturity of marriage age, and function of the family12. are usually depended on the country regulation3. Annually, BKKBN establishes GenRe program to select the student ambassador for campaigning and doing Pap smear screening test is popular method healthy sexuality education after received intensive worldwide. The specimens will be taken from the face training from BKKBN. of cervix and endocervix using a spatula or brush and transferred to a slide. Moreover, the sample should be Male Circumcision. WHO recommends for appropriately labeled and transported to the laboratory Voluntary Medical Male Circumcision since 2007 for interpreting the result3. not only for reducing the risk for cervical cancer but also reducing the risk of HIV/AIDS. Previous studies VIA is used for detecting early cell changes that revealed that female partners of circumcised men have a are visible when using a speculum with the naked eye 13,14 significantly lower risk of cervical cancer . after applying dilute (3–5%) acetic acid on it. VIA is recommended for women before 50 years old. VIA The global map also reported that all of the countries testing can detect both early changes and more advanced initiate the male circumcision. Globally, around 37% pre-cancer. VIA can be performed by trained providers, to 39% men are circumcised15. In the US, health with adequate visual acuity at any level of the health professionals influence the parents to allow their son system. VIA is a subjective test and it depends on obtain circumcision after birth because the insurance will provider’s skills and experiences. Due to the subjective cover the neonatal circumcision16. In addition, WHO, nature of the test, quality control and quality assurance UNAIDS, the World Bank, the American Academy of for VIA is particularly important through supervision Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 527 and routine monitoring3. should be provided by health professionals for women with a positive result of cervical cancer screening test. Molecular HPV testing methods are based on the The treatment usually offered in primary care health detection of DNA from high-risk HPV types in vaginal services such as PHC or primary clinic. The treatment and/or cervical samples. HPV testing is highly sensitive usually includes ablation or excision3. for detecting HPV infection in women. However, it requires proprietary supplies and equipment, which may Tertiary Prevention not be easily accessible and the unit cost is expensive. WHO recommends the tertiary prevention including HPV testing is recommended for women over 30 year, treatment and palliative care3. The primary care services or the age specify in updated national guidelines. A should refer the patient to advanced health care services health-care provider can collect a sample of cells by for obtaining appropriate treatment and accessing inserting a small brush or another device deep into palliative care. the vagina and place it in a small container with an appropriate preservative solution. It is also applicable Patients with cervical cancer need surgery, 3 during speculum examination or self-collection . radiotherapy or chemotherapy3. The treatment depends on the stage of cancer, patient’s health status, and Indonesia has already established Pap smear and availability of current facilities and expertise. The VIA as the national program to detect cervical cancer. patients usually obtain surgery or radiotherapy as The MoH Indonesia determines the target population primary therapy, with or without chemotherapy. In of the screening test is women aged 30 to 50 years18. general, hospitals provide the treatment while primary The implementation of test is conducted in the PHC, health care services refer the patients to the hospital3. private clinic, and hospital. The screening test is mostly performed by public health physicians and midwives Palliative care for cervical cancer patients comprises under supervised by gynecologists, district and the prevention and relief of some suffering symptoms 19 provincial MoH . such as pain, physical and psychosocial symptoms, and spiritual suffering to achieve best quality of life In Indonesia, the Pap smear is recommended for every for patients and family and prepare the dignity in end two years and VIA once per year for three consecutive of life for advanced cancer patients. WHO recommends years18. When finding a positive result of the screening palliative care should consist multidisciplinary team test, providers will directly inform the women and offer including physicians, nurses, community health worker, rapid treatment or advanced examination. Data MoH and family caregivers3. of Indonesia reported that approximately 1.5 million women already obtained VIA test and 3.5 million got In Indonesia, the tertiary prevention of cervical 18 Pap smear . cancer in PHC is focused on palliative care rather than treatment. The implementation of palliative care in PHC Although the regular Pap smear successfully is still limited. Balongsari PHC in Surabaya is the pioneer reduced the incidence and mortality rates for cervical of implementation palliative care in the community since cancer, there are barriers to implement Pap smear such 200721. The provisions of palliative care in Balongsari as limited number of the pathologist in Indonesia18. including outpatient service of palliative and pain-free Therefore, Indonesian government established VIA as every Monday and Wednesday morning and palliative the alternative methods in cervical cancer screening home care every month. The team includes physicians, that feasible and applicable in the facilities with low nurses, volunteers, and a palliative team from the resources. VIA is a relatively new method for cervical hospital21. cancer screening in Indonesia. However, it is growing in six provinces: North Sumatera, South Sulawesi, Conclusions West Java, DI Yogyakarta, Central Java, and East Java Province20. A comprehensive cervical cancer prevention program includes primary, secondary, and tertiary Treatment of Pre-cancer. Pre-cancer treatment prevention in preventing and reducing the morbidity 528 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 and mortality of the disease. HPV vaccination, healthy Accessed 6 January 2018. sexuality education, and male circumcision belong to 8. Harsianti J. HPV vaccine for cervical cancer primary prevention are well implemented worldwide. prevention: Yes or no? http://www.thejakartapost. Pap smears and VIA are popular and well-applied com/life/2017/07/26/hpv-vaccine-for-cervical- in Indonesia. Indonesia has implemented primary, cancer-prevention-yes-or-no.html. Accessed 1 secondary, and tertiary prevention of cervical cancer December 2018. according to the national policy of the MoH. Currently, 9. Sitepu M. Fact about cervical cancer the HPV vaccination, Pap smears, and VIA are monitored vaccination. http://www.bbc.com/indonesia/ and evaluated. indonesia-38131404. Accessed 1 December 2017. Conflict of Interest: None. 10. Setiawan D, Dolk FC, Suwantika AA, Westra TA, WIlschut JC, Postma MJ. Cost-utility analysis of Funding: None. human papillomavirus vaccination and cervical Acknowledgements: We would acknowledge screening on cervical cancer patient in Indonesia. Professor Ching-Min Chen, who provided invaluable Value Health Regional Issues. 2016;9:84-92. support and suggestion throughout this article. 11. Shepherd J, Peersman G, Weston R, Napuli I. 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Tobian AA, Gray RH, Quinn TC. Male circumcision 7. Global Alliances for Vaccine and Immunization. for the prevention of acquisition and transmission Application Form for Human Papillomavirus of sexually transmitted infections: The case for Vaccine Demonstration Programme: Indonesia. neonatal circumcision. Archieves of Pediatrics and https://www.gavi.org/sites/default/files/document/ Adolescent Medicine. 2010;164(1):78-84. proposal-for-hpv-demo-support--indonesiapdf.pdf. 17. Morris BJ, Hankins CA. Effect of male circumcision Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 529 on risk of sexually transmitted infections and Vietnam. Vaccine. 2008;26:M71-M79. cervical cancer in women. Lancet Global Health. 20. Nuranna L, Aziz MF, Cornain S, Purwoto G, 2017;5(11):e1054-e1055. Purbadi S, Budiningsih S, et al. Cervical cancer 18. MoH of Indonesia. 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Indonesia, Malaysia, the Philippines, Thailand and . 530 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13901 Developing Mobile Application for Predicting Risk of Cardiovascular Event among People with Diabetes: Design and Pilot Study Anggi Lukman Wicaksana,1,2, Andri Cipta3, Nadhifah Azzahrah Yumna3, Muhammad Nabhan Naufal4 1Assistant Professor, Department of Medical Surgical Nursing, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada (FMPHN UGM), Indonesia, 2Researcher, The Sleman Health and Demographic Surveillance System, FMPHN UGM, Indonesia; 3Student, School of Nursing, FMPHN UGM, Indonesia; 4Student, School of Information Engineering, Faculty of Engineering, UGM, Indonesia Abstract Aims: The study aim is to develop a mobile application (app) design for predicting the risk of cardiovascular event and conducts a pilot study. Methods: The mobile app design was developed on the basis of evidence from World Health Organization (WHO) and International Society of Hypertension (ISH). The workflow had four steps, namely; data entry, conversation and processing, risk identification, and education. The development process involved interface designing, coding, debugging, and pilot testing. Cross-sectional approach for pilot testing was conducted by using system usability scale. Results: Main features of the Decardia app, namely, icon categories, input slots, risk identification outcomes, and education windows, were developed. The app is available in Android platform and in offline mode, compact, accurate, efficient and users involvement for education. The pilot outcomes indicated excellent (60%), acceptable (95%), and grade A+ with an average overall score of 87. Almost all components of usability testing showed positive results with scores ranging from 3 to 3.95 (out of 4). Conclusions: The Decardia app evaluates patient’s risk level of cardiovascular event and empowers their risk reduction behavior. The pilot study indicated positive outcomes, supporting the usability of the Decardia app. Keywords: cardiovascular event, diabetes, design, mobile health, risk of cardiovascular, screening Introduction Data from the Ministry of Health Indonesia shows that 12.2 million people have diabetes, and the number will Asia Pacific region contributes the greatest grow in the following year2. Diabetes is also responsible prevalence of diabetes. In Southeast Asia, diabetes for 1.6 million deaths and is the sixth cause of death3. was identified among 85 million people in 2017 and is projected in approximately 151 million people in 20451. Most diabetic people die due to cardiovascular complication. American Heart Association reported that Correspondence: 65% of diabetic people die because of heart attack and Anggi L. Wicaksana, stroke4. Furthermore, people with diabetes are at high- Department of Medical Surgical Nursing, FMPHN risk of having cardiovascular attack5. Thus, initiatives of UGM, Ismangoen Bd. 2F, Jl. Farmako, Sekip Utara early detection and risk reduction are critical. The WHO Kompleks FKKMK, Yogyakarta, Indonesia, 55481. publishes a guideline for evaluating and controlling Telephone: +62-274-545674 fatal cardiovascular occurrence for the next 10 years. E-mail: [email protected] Risk of cardiovascular event is assessed by considering Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 531 individual data which are designated in the risk prediction applicable tools and applied a widely used instrument chart6,7. The existing tool helps people with diabetes and model from WHO/ISH6,7. health care workers (HCW) to understand their risk of Researchers applied the cross-sectional design cardiovascular incident. among clinicians in primary healthcare (PHC) in Risk prediction is proposed for primary care settings Yogyakarta. Clinicians were invited to appraise the and hospitals, and the chart is available in simple form. Decardia app on September 2019. All physicians and Risk identification is considerably self-deciding, time nurses in charge in PHC were requested to use the consuming, and potentially confusing. Therefore, most Decardia app. clinicians ignore detection due to limited time, and few Instruments people with diabetes evaluate their risk. Ignorance of cardiovascular risk level may contribute to the further The development of the Decardia app was based 6,7 development of stroke and heart attack . HCW and on the WHO/ISH risk prediction chart. To conduct the diabetes people should focus on specific risk level and usability testing, researchers used system usability scale undertake action to decrease the risk. (SUS). The guideline for cardiovascular event risk is The risk level of cardiovascular incidents were available in manual and English versions, which may identified then classified on the basis of the WHO/ISH be impractical for diabetes population in Indonesia. In risk prediction chart. It is commonly and widely used addition, recommendations related to risk reduction instrument in assessing the fatality or non-fatality of are available, but they are written in complicated cardiovascular event (heart and stroke attack) in the next and medical languages, which may be inapplicable 10 years. Risk prediction level is based on age, gender, 6,7 for diabetic people . Therefore, the guideline must SBP, smoking status, non-fasting blood cholesterol, and be simplified. Diabetes people and HCW need an presence/absence of diabetes6,7. ingenuous but understandable tool to evaluate their risk of cardiovascular event. Developing a mobile app as an The WHO/ISH risk prediction chart is available in assessment device for helping diabetes people and HCW 14 epidemiological sub regions with and without blood can be an appropriate solution. Therefore, researchers cholesterol data and with and without diabetes6,7,8. decided to develop a mobile app to calculate the The WHO/ISH risk prediction chart Southeast cardiovascular risk level among people with diabetes. Asian Region (SEAR) B is used in Indonesia7,8. The Furthermore, the app is expected to promote healthy instrument can modestly grade the cardiovascular risk lifestyle among diabetes people. level among the high-risk population. The instrument is also recommended when assessing the risk level in The objective of this research is to describe the PHC or hospitals. The chart uses five colors for four development process of mobile app, namely, Decardia risk stratifications; green for low (< 10%), yellow for for assessing risk of cardiovascular event among diabetes moderate (10%–19%,), orange for high (20%–29%), people. Thus, the primary outcome is a Decardia design and red/dark red for very high-risk (≥ 30%). To develop for diabetic people. In addition, the pilot study outcomes the Decardia app, the researchers used the SEAR B chart among clinicians are presented as preliminary results. for diabetic people with cholesterol data6,8. Methods SUS was employed to identify subjective testing for Study Design product usability. SUS is expansively used to test various systems and apps in a relatively short time, including The development process of the Decardia app software, hardware, websites, and mobile platforms. originated from literature on assessing the cardiovascular SUS is a simple tool that consists of 10 questions, with risk level among people with diabetes. A comprehensive a five-point response scale: strongly disagree (0) to search was conducted using proxy and academic strongly agree (4). To compute the scores, items 1, 3, databases. Researchers identified available and 5, 7, and 9 should be minus 1, whereas the rest items 532 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 must be 5 minus the item score. Summing up the 10 item directly choose an icon as their condition. Researchers scores and multiplying them by 2.5 generated the total then built program coding by using Android Studio to score. SUS has ranging scores 0-100, and 68 is perceived assure the algorithm for determining the cardiovascular as the average score9–11. risk level through the WHO/ISH risk prediction chart. Debugging was performed to check whether errors or The SUS scores are also translatable to letter bugs existed. If so, then the coding process was repeated grades which are helpful for presentation and until the problems/errors disappeared. The researchers communication9,10,12. Bangor et al.13 and Brooke11 checked and tried the Decardia app for pilot testing. suggested converting SUS scores into adjective rates (good, poor, etc.) and acceptability ranges. Ethical Concern Mobile App Development The UGM ethical committee granted ethical approval. Clinicians received material for testing, Decardia was developed using Android platform, including trial of the Decardia app, and signed a consent considering the major smartphone users in Indonesia14. form for participation. Only research team could access Supporting software for Android, namely, Java data. Development Kit, Android software development kit, and Integrated Development Environment (IDE), were Clinical Evaluation and Testing first installed. Android Studio was selected as IDE it Usability testing was performed among clinicians in has complete features. Mind mapping was then made to PHC. This test was a validation phase to explore their determine the Decardia app specification and workflow. evaluation on the Decardia app. Researchers requested Considering the evidence, four steps of the app permission from the local government and PHC for data workflow were generated: a) data entry, b) conversion collection. Clinicians were approached during working and processing, c) risk level identification (output), and hours by previous appointments. The research team d) education (Figure 1). introduced the Decardia app and allowed clinicians to The Decardia app workflow starts by inputting operate it. Clinicians received research project description patients’ data (age, cholesterol level, SBP, gender, and and were asked for their voluntary participation. Only smoking status) into the app. Patients’ data can determine those who agreed signed the form and continued data specific cardiovascular risk levels by processing an collection. All the participants needed to complete SUS algorithm as the guideline from the WHO/ISH risk regarding their immediate response to the Decardia app. prediction chart6,7,8. In a short time, the outcome of Data Analysis processing phase can show the cardiovascular risk level. Four grades (low, moderate, high, and very high-risk) The analysis focused on the presentation of pilot indicate risk levels according to the guideline. Based study outcomes. The average SUS score, grading letter, on users’ risk level, they are guided to the education acceptability range, and adjective rating were presented. windows, which provide information on recommended To gain further information for the overall score and actions to reduce their risk level and prevent each score, data were described using the radar chart cardiovascular occurrence. using excel spreadsheet. The development process of the Decardia app Results consists of four phases: interface designing, coding, debugging, and pilot testing. An interface user was The Decardia Outlook and Mode designed for the Decardia app features, such as cover The Decardia app cover displays a heart and a start display, dashboard, input slots, risk classification level, button. It shows the risk prediction level of cardiovascular and education windows by using Adobe experience event among diabetic people. The main features of the design. For simplification, diabetes users only entered Decardia app are icon categories (gender- and smoking- their age, cholesterol level, and SBP. Gender and smoking based), input slots (age, cholesterol, and SBP), risk status were available as optional icons. Thus, users could classification, and education windows (Figure 2). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 533 The Decardia app is also available in offline mode. from PHC. The average score is 87, indicating an To use this app, users must download and install it “excellent” adjective rating and an acceptable outcome. from Google Play (https://play.google.com/store/app/ For the grading scale, the score of 87 is equal to grade B details?id=com.app.decardia) by using a smartphone (Figure 3)11,13. Sauro and Lewis recently presented the (minimum series 4.0.3 or above). Users should then new grading scale on the basis of the dataset percentile open the app, select a category, input current data, and and made another detail option of grading scale9,10,12. press the “count risk” button to obtain the risk level of Using this standard, the pilot study outcome indicated cardiovascular event within the next 10 years. Last, the grade A+ (84.1–100). Among all participants, most education windows show recommendations for users. respondents indicated acceptable (95%) and excellent (60%), supporting the overall score of the perceived The Decardia App Features usability of the Decardia app (Table 1). The Decardia app features focus on the risk level A detailed score of the subjective usability testing prediction of cardiovascular event. This app also provides was indicated for each component. The original score education windows for diabetes people. It empowers close to number 4 showed the highest score among patients to reduce and maintain their risk level. The app all components. The detailed score of the Decardia is also applicable for HCW in assessing the risk level of app is available in the radar chart (Figure 4). Among cardiovascular event and educating diabetes people. all components, the highest and lowest score were Pilot Study of Usability Testing convenient (3.95 of 4) and well integrated (3 of 4), respectively. The usability testing was conducted among clinicians for a month. Twenty clinicians were recruited Table 1 Distribution of the Decardia app scores (n=20) Acceptability range Adjective rating Category n % Category n % Unacceptable (0–50) 0 0 OK (52–72) 1 5 Marginal (51–70) 1 5 Good (73–84) 7 35 Acceptable (71–100) 19 95 Excellent (85–99) 12 60 534 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Figure 1. The Decardia app workflow. Figure 2. Display design of the Decardia app (Indonesian), (a) cover display, (b) dashboard of icon category, (c) input slots, (d) risk clasification outcome, (e) education windows option, (f) education windows. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 535 Figure 3. The Decardia app outcome. Figure 4. Radar chart of the Decardia app. Discussion the Decardia app among the prospected users16. The Decardia app is available in the Android User perception on the Decardia app was also platform. The app focuses on risk identification and explained in the usability testing in the pilot study. The education for engaging diabetic people to reduce their overall score indicated positive and good outcomes where risk. Clinicians’ subjective usability indicated positive the score of 87 showed an acceptable outcome (70–100) outcomes (acceptable, excellent, and grade A+). They for acceptability range and an excellent indicator (80– were satisfied with the Decardia app. The development 90) for adjective rating. Clinicians’ appraisal on how the and pilot study invited clinicians as app users. Such an Decardia app works as a relatively new system was also invitation is a part of a design-based research approach confirmed9,11–13. Interestingly, the grading letter labels that concerns user involvement during the developing had points B and A+ for the same score. Both grading phase15. Clinicians were involved to understand their scales depended on the custom standard. Bangor et agreement, engagement, and perception. Such an al.13 and Brooke11 preferred grade B for the scoring involvement is also an appropriate approach to introduce range between 80 and 90. The standard was defined as 536 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 the general school grade with the average of 70, which Acknowledgements: The authors highly appreciate indicates a passing grade. By contrast, Sauro and Lewis all staffs in Students Affair and PKM Center, UGM for presented a different grading scale9,10,12. They graded helping facilitate research and all pilot participants who scores by using the SUS percentile with an average score engaged in research. of 68 and provided further detailed labels (Table 1). Therefore, the outcome was grade A+ (84.1–100). Both References grading systems have their own reason, but researchers 1. International Diabetes Federation. IDF Diabetes agreed to apply Sauro and Lewis’ grading scale because Atlas 8th Edition. https://www.idf.org/e-library/ it is realistic, detailed, and easy to communicate among epidemiology-research/diabetes-atlas/134-idf- stakeholders9,10,12. diabetes-atlas-8th-edition.html. Accessed 21 March 2019. The Decardia app is established to assist risk 2. Kementrian Kesehatan. Riset Kesehatan Dasar. identification and educate risk reduction behavior. The Jakarta: Kemenkes RI. 2013. app can be developed for other platforms and without 3. WHO. Diabetes. https://www.who.int/en/news- cholesterol data. The Decardia app is only doable in room/fact- sheets/detail/diabetes. Accessed 30 the Android platform. Diabetes people and educators October 2018. must consider Android phones to use the Decardia 4. American Heart Association. Cardiovascular Disease app. The risk prediction chart from WHO/ISH is also and Diabetes. http://www.heart.org/HEARTORG/ available without cholesterol data6. The Decardia app Conditions/More/Diabetes/WhyDiabetesMatters/ only provides risk assessment by utilizing cholesterol Cardiovascular-DisiaseDiabetes_UCM_313865_ data. The app systems also need improvement for “data Article.jsp. Accessed 17 October 2018. saving” features, which thus become comparable and 5. Kozakova M, Polombo C. Diabetes mellitus, recordable. arterial wall, and cardiovascular risk assessment. International Journal of Environmental Research Conclusions and Public Health. 2016;13(2):201-214. The Decardia app is available in Google Play. The 6. WHO. Prevention of cardiovascular disease, app has four steps of workflow: data entry, conversion and guideline for assessment and management of process, risk level identification, and education. Decardia cardiovascular risk 1st edition. Geneva: WHO. app primarily suggests diabetic people to evaluate their 2007. risk level of cardiovascular event and empowers them for 7. WHO. Prevention of cardiovascular disease, risk reduction. The app is compact, accurate, efficient, pocket guidelines for assessment and management has education windows, and is available in offline of cardiovascular risk 1st edition. Geneva: WHO. mode. However, Decardia app cannot store data, is only 2007. Android-based, and only manually inputs data. The pilot 8. Aini FN, Wicaksana AL, Pangastuti HS. Tingkat study revealed satisfactory outcomes (87 of 100) and risiko kejadian kardiovaskular pada penyandang indicated excellent, acceptable, and grade A+ results. diabetes tipe 2. Journal of Indonesian National Moreover, all components obtained scores ranging Nurses Association. 2019;4(3):182-192. between 3 and 3.95, indicating positive outcomes. The 9. Klug B. An Overview of the system usability scale Decardia app helps people with diabetes and health care in library website and system usability testing. providers in assessing their cardiovascular risk level and Weave: Journal of Library User Experience. educating them about risk reduction behavior. 2017;1. 10. Lewis JR, Sauro J. The factor structure of the Conflicting of Interest: None system usability scale. In: International conference Funding: Ministry of Research, Technology, and on human centered design. Berlin, Heidelberg: Higher Education, Indonesia supported this work in Springer; 2009:94-103. 2019 as part of a student creative program in UGM. 11. Brooke J. SUS: a retrospective. Journal of Usability Studies. 2013;8(2):29-40. Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 537 12. Lewis JR. The system usability scale: past, present, 15. Petersen M, Hempler NF. Development and testing and future. International Journal Human Computer of a mobile application to support diabetes self- Interaction. 2018;34:577-590. management for people with newly diagnosed 13. Bangor A, Kortum P, Miller J. Determining type 2 diabetes: a design thinking case study. what individual SUS scores mean: adding an BMC Medical Informatics and Decision Making. adjective rating scale. Journal of Usability Studies. 2017;17:91. 2009;4(3):114-123. 16. Årsand E, Frøisland DH, Skrøvseth SO, Chomutare 14. Meiliana, Irmanti D, Hidayat MR, Amalina NV, T, Tatara N, Hartvigsen G, Tufano JT. Mobile Suryani D. Mobile smart travelling application for health applications to assist patients with diabetes: Indonesia tourism. Procedia Computer Science. lessons learned and design implications. Journal of 2017;116:556-563. Diabetes Science and Technology. 2012;6:1197- 1206. 538 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 DOI Number: 10.37506/ijphrd.v12i1.13902 A Review of Harmful Aspects of Mobile on Health and Environment Monika Dubey Faculty, Department of Management Studies, Rajasthan Technical University, Kota Abstract Background: Cell phone based on communication and digital technology has become inseparable element in life of users and has proved to be a panacea of all information and communication needs over the years. But as a necessary evil it may cause harm to both health and environment. Objectives: It is envisaged to be aware of the potential health hazards, dos and don’ts towards healthy use of cell phone. The aims to create a background to find level of awareness for health aspects related to mobile phones and disposition behaviour for discarded mobile phones based on previous studies. Methods: The study highlights the harmful aspects of mobile on health and environment from the literature review perspective. Results: Review of previous studies show that there is very less awareness for harmful effects of mobile phones on health and environment. Disposition of EoL mobile phones in proper manner is very limited. Conclusion: Studies indicate the risks associated with cell phone due to its electromagnetic fields (EMF) while in use and health hazards at the end-of-life or not in use or discarded mobile phones. Therefore healthy disposal methods of mobile phones in the context of sustainable electrical and electronic equipment waste management have also emerged as a significant issue. Keywords: electromagnetic radiations, e-waste management, mobile phones, SAR Introduction Methodology Over the years mobile phones have entailed The study aims to study the ill-effects of in-use and revolutionary changes in the lifestyle of people. But end-of-life mobile phones on the health of the users and as an innovation with mixed blessings, problem of environment. It is based on review of text concerned electromagnetic radiations (EMR) when in use and with projecting the harmful impact of EMR on the health e-waste is also arising from discarded mobile phones of users, along with literature highlighting the need and posing considerable environmental and health risks. for e-waste management of discarded mobile phones and introducing government regulation of Extended Huisman et al. 1 rightly indicated that the most Producer Responsibility. It also reviews the awareness frequently sold appliances into the households are of users worldwide for this concern. mobile phones. Like any other technology its excessive use and absurd usage habits are also likely to cause harm. Mobile Phones and EMR It is for this reason that cell phones are often referred as a ‘health time bomb’, which while communicating with Cell phone market is characterized by rapid the cellular network emits low level of radio waves (also technological change as a result of which the dependence known as Radio Frequency or ‘RF’ energy or EMR).2 on the cell phone is also increasing exponentially. Hence, one gets exposed to these EMR (Electro Magnetic Although there is consensus among researchers on the Radiations) or MPR (Mobile Phone Radiations) which concern that radiations emitted by cell phone have an may be dangerous and become a serious health risk. impact on human beings, but no concrete scientific assessment of the impact of mobile phone radiations Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 539 (MPR) on human beings is available. that the customers can make an informed and judicious decision before each purchase. From 1st September A significant number of individual, 2013, only the mobile handset or cell phone with epidemiological and experimental research studies also revised SAR value of 1.6W/kg averaged over 1 gram suggest inconclusive causative relationship between of human tissue is permitted to be manufactured or exposure to cell phones and harmful biological effects imported in India. The limits for SAR are determined by in humans. However, in 2009 Lennart Hardell and other the strength of the electromagnetic field that reaches the authors of a meta-analysis of 11 studies from peer- body in average 30 minutes when the cell phone is held reviewed journals concluded that cell phone usage for at at the ear. This limit ensures that the equipment like cell least ten years “approximately doubles the risk of being phone is operating within the optimum and permissible diagnosed with a brain tumor on the same (‘ipsilateral’) parameters. Even if there are differences in SAR levels side of the head as that was preferred for cell phone use.” among cell phone models, all of them must at least meet The World Health Organization (WHO)3 has RF exposure prescribed guidelines. Compliance with extensively reviewed studies on mobile phone safety and these norms has made Indian telecom regulations 10 has included mobile phones in Group 2B, i.e. ‘possible’ times more rigid than they are in over the 90% of the human carcinogen indicating that there is convincing countries in the world (Table 1). evidence that this agent causes cancer in experimental From January 25, 2012 onwards, all foreign animals. However there is lack of information whether it (manufacturing for sales in India) and indigenous causes cancer in humans or not. manufacturers of handsets were instructed by the The Bio Initiative Report 2012 (BIR-2012) on Department of Telecommunications, India to make standards for electromagnetic radiations claimed that the compatible changes in the design, software and evidence for risk to health from wireless technologies packaging of their respective handsets as per prescribed 5 and electromagnetic fields (EMFs) has substantially limits which were imposed from September 1, 2013. To increased since 2007.4 regulate indigenous as well as imported mobile phones, standards for all mobile phones have been framed under In woke of above studies the most stringent and the BIS Act 1986 and Bureau of Indian Standard (BIS) strict international norms that limits the SAR value ensures the compliance of provisions of the act by the (Specific Absorption Rate - a measure of the rate that manufacturers. Therefore, all mobile phone handsets body tissue absorbs radiation energy during cell phone sold in India now comply with relevant Bureau of use) of cell phone handsets have been adopted in India Indian Standard’s (BIS) benchmark.6 One can check in order to comply with the guidelines issued by DoT, the information of SAR value of any mobile phone by Department of Telecommunications.5 Regulations dialling *#07#, the Unstructured Supplementary Service notified by the Government of India requires for every Data (USSD) code on the respective mobile phone. mobile handset to display the SAR value of the model so Table 1: SAR Values for Mobile Handsets of Some Countries Country SAR Value Limits China 2 W/Kg averaged over 10g of tissue Singapore 2W/Kg averaged over 10g of tissue Ghana 2W/Kg averaged over 10g of tissue Brazil 2W/Kg averaged over 10g of tissue Nigeria 2W/Kg averaged over 10g of tissue Japan 2W/Kg averaged over 10g of tissue 540 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Cont... Table 1: SAR Values for Mobile Handsets of Some Countries Republic of Korea 2 W/Kg averaged over 10g of tissue Europe 2 W/Kg averaged over 10g of tissue Australia 1.6W/Kg averaged over 1 g of tissue USA 1.6 W/Kg averaged over 1 g of tissue Canada 1.6 W/Kg averaged over 1 g of tissue Source:http://www.trai.gov.in/sites/default/files/ contain lead, mercury, nickel, bromine, chlorine, EMF%20Information%20Paper_30.07.2014.pdf phthalates. Headphone contains PVC with phthalates over 1-5% by weight.10 One mobile phone contains Although very few consumer studies on cell phone more than 30 elements precious metals like gold, cobalt, usage and handling patterns exist, even though some palladium, and rhodium. studies associate cell phone usage and hazardous to health behaviors. Such materials can be recovered, recycled and reused to make a variety of other products thus Johansen et.al.7 suggested that users who wish to reducing incineration, landfilling and health risks to refrain themselves from radiofrequency exposure can the community. Recycling may include disassembly limit their exposure, by using an ear piece and reducing and shredding. Disassembly means dismantling of cell phone use, particularly addressing children. Panda et packages and plastics that may be recycled and thus al.8 conducted a study at PGIMER, Chandigarh, which may reduce landfills. Shredding includes recovery recommended following two ways for evading from the of metals and minerals that may be utilized in future. harmful rays emitted by mobile phones. But due to unawareness mobile phones are put to end either through the process of improper incineration • Mobile phones should not be used continuously that releases dangerous toxins in the atmosphere or and not more than one hour in a day. Hands free landfilling that results in piling up of waste and leaching technology to be used where excessive use of the mobile of the harmful substances from the decomposing waste phone is unavoidable. Microphones and Bluetooth which contaminates both groundwater and soil. should be used so that the handset remains away from the ear and thus evades the direct impact of harmful Government of India has formulated and notified electromagnetic radiations on the ear and the brain. its strategy to tackle the E-waste through the E-waste (Management) Rule, 2016 which remarks that • People should avoid calls and discussions of manufacturers of electronic goods are responsible for long duration on mobile phones as far as possible. their products once these have outlived their utility, which Saini9 attempted to explore the awareness of the has been termed as ‘Extended Producer Responsibility’ student community in Delhi (India) on the issue of MPR (EPR). Therefore, the mobile phone producer is also and its health impact and also about regulations such responsible for “setting up collection centres or take-back as SAR (Specific Absorption Rate). The analysis of the (electronic) systems either individually or collectively”. survey reflected that very little awareness exist among Despite enforcement of E-waste (Management) Rules, the respondents for SAR value and about 88% of them 2016, the government set up is still ineffective to ensure were not aware of what SAR means in terms of MPR industrial sectors conform to the regulations outlined. with respect to a mobile phone. Therefore, only 1.5% of the country’s e-waste is DISPOSAL OF END-OF-LIFE MOBILE recycled. Used mobile phones as well as other small PHONES WEEE (Waste Electrical and Electronic Equipment) or mobile accessories to a great extent still find their way to Cell phones are made up of toxic chemicals that Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 541 residual waste bins and eventually to landfill. The biggest use and disposal of mobile phones. Most people change obstacle in recycling is the lack of consumer awareness their phones every one to two years. However, despite on collection and recycling possibilities, leading to low asserting that mobile phones should be recycled, repaired collection amounts. Without returning products for or reused, and demonstrating awareness of the hazards recycling the next phases, technical recycling processes, and toxicity of mobile phones, 86% of people store their cannot take place. ‘retired’ phones, with almost half, having three to four phones stockpiled. The small size and light weight of As far as not in use mobile phones are concerned it mobile phones make stockpiling an easy option and is a general practice in India to keep old but functional create obstacles for ‘take-back’ and other more formal cell phones are as back-ups, sell or hand over to others ways of reuse or recycling. or exchange for a discount on a new cell phone against a promotional offer. But non-functional mobile phones Li, Yang, Song and Lu13 conducted an online are stockpiled at their end of life either for the sake survey among university students in China to identify of emotional attachment of the consumers or due to the disposal behavior and awareness of sustainable absence of post-Consumer Waste Recycling and Optimal management of retired mobile phones. The results Production mechanism for disposed of cell phones in showed that about 22% of the respondents replaced the respective city. Studies show that consumers have their mobile phones annually, while most respondents very less awareness that mobile phones are made up of replace their phones in 2-3 years. The most common recyclable and renewable material that can be put back reason for mobile phones replacement was physical into circulation through proper recovery mechanism, broken. 64% of the respondents stockpile their most reducing the health risks to the community. recently retired phones mainly due to lack of formal management system. The survey results on mobile In India over 95% of the e-waste is managed by the phones consumers’ environmental awareness also can unorganised sector and scrap dealers, who dismantle the help improve the policy-making. Nearly 50% of the discarded products instead of recycling them. Severe respondents believe the recycling cost of the retired health impacts and environmental damage are phones should be shared by all the stakeholders. widespread in India due to this final step of the e-waste Yin , Gao & Xu14 conducted a questionnaire survey processing by the informal sector. From perspective was performed in China to explore consumers’ of Occupational Hazard, e-waste handlers are also at behaviors, attitudes and willingness to pay (WTP) for a much higher risk majority of which are women. The recycling waste mobile phones. The responses of 1035 Emissions of Toxics into the environment is another respondents were analysed using principal component aspect to consider. The material flow in and out of the analysis and multinomial logistic regression analysis. system is totally unmonitored at present. The results reflected that the actual service life of cell There must be serious concern for research in this phones in China is generally shorter than three years. field as very less literature is available worldwide to Due to the current level of economic development ascertain the awareness of users for the issue. This is and the traditional concept, only 47.9% of consumers emerging out as global problem and will very soon add agreed to pay for waste mobile phone recycling, and huge amount to the e-waste with the switching of the most consumers’ WTP was 0-5% of the recycling costs. users from 4G to 5G telecommunication. The main factors affecting the consumers’ WTP were region, education level and monthly income. The need Disposition practices for end-of-life electronics is for improving public environmental awareness was a key step in developing policies that prevent negative felt which will make possible for consumers to afford environmental and health impacts while maximizing recycling fees. potential for positive social and economic benefits though reuse.11 Speake Janet & Leopoul Nchawa Mobile phones have short lifecycles and because Yangke12 surveyed 250 people in Liverpool UK using of their (perceived) in-built obsolescence. Discarded mixed methods quantitative and qualitative approach mobile phones contribute to the growing problem of 15 to investigate their attitudes and perspectives towards waste electrical and electronic equipment (WEEE). 542 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 The initial scheme of take-back was launched in UK reveals that 55% of respondents have two or more in 1997. These take-back schemes significantly play unused mobile phones at homes. The more phones stored an important role in sustainable waste management at homes, the more often reasons ‘I don’t know where to by diverting EoL mobile phones from landfills and return’ and/or ‘have not got to do it yet’ were mentioned. encouraging reuse and recycling. This indicates that proximity and the convenience of current waste management system are inadequate Ongando F.O., Willliams I.D16 conducted a survey in promoting the return of small waste electrical and of students at 5 UK universities to assess their behaviour electronic equipment (WEEE). To facilitate re-use, with regard to their use and disposal of mobile phones. and the highest level of recovery, consumers will need The findings indicate that many students replace their to be committed to return end-of-use electronics to phones at least once a year; replacing broken phones, WEEE collection centres without delays. Further, the getting upgrades from network operators, remaining supply and demand of refurbished mobile phones do “fashionable” and a desire to have a handset with a not meet at this moment in Finland due to consumer’s longer battery life are the main reasons for such rapid storing habits versus expectations of recent features replacement. Almost 60% of replaced phones are not under guarantee and unrealistic low prizes. The study sent to reuse or recycling operations but are stockpiled also points out that, in order to change current storing by students mainly as spare/backup phones. habits of consumers, there is an explicit need for more Akhtar, Masud, and Afroz 17 conducted a study to information and awareness on mobile phone collection ascertain household awareness, knowledge and risk in Finland, especially on regarding retailers’ take-back. perception of e-waste and its impact on attitudes and Consumer’s disposal choices as to how and when recycling behaviors in Kuala Lumpur. The result shows they dispose of a mobile phone impact the volume, that three factors, namely, awareness, knowledge and timing and condition of goods entering the reverse risk perception of e-waste management have positive supply chain.20 Therefore consumers’ disposal and significant influence on attitudes towards e-waste decisions are of high relevance in the recycle chain management. Furthermore, attitude towards e-waste or reverse logistics and thus prove to be detrimental management has a positive influence on recycling for the environment as a whole. Therefore, consumer behavior. This study provides valuable insights to awareness of harmful effects of in use and end-of-life policy makers so that they may take appropriate steps mobile phone is of utmost importance. Marketing plays to increase recycling behavior among households in a significant role in creating consumer awareness and Kuala Lumpur. In a similar study by them more than disseminating information about the impact of products 30% of the respondents informed that they give away on environment, personal health and society.21 their discarded electric and electronic equipment (EEE) including mobile phones to charity or to relatives if they Conclusion cannot repair them.18 Only a small fraction of the used There is a need for users to understand that the EEE could reach recycling facilities and manufacturers revolutionary telecommunication based invention as there is no efficient take back scheme for consumers. can prove to be curse if it is not used judiciously and Yla-Mella, Jenni & Keiski, Riitta & Pongracz in a healthy manner. It can prove to harmful to the Eva19 examined consumers’ awareness and perceptions environment even in its end-of-life stage if not disposed towards mobile phone recycling and re-use. The results of properly. Many of the parts of a mobile phone are are based on a survey conducted in the city of Oulu, recyclable which can only be recovered sustainably if Finland, and analysed in the theoretical framework based returned back to the producer. on the theories of planned behaviour (TPB) and value- Ethical Clearance: Taken from Research belief-norm (VBN). The research findings indicate that Committee, RTU, Kota consumers’ awareness of the importance and existence of waste recovery system is high; however, awareness Source of Funding- Self has not translated to recycling behaviour. The survey Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 543 Conflict of Interest - Nil Development. 2017;2(1): p. 44-7. (10) Schmidt Anders, Bjarnov Erik & Nielsen References Brandt Tenna. Survey Report of Chemical (1) Huisman, J., Magalini, F., Kuehr, R., Maurer, Substances in Consumer Products, No. 91 C., Delgado, C., Artim, E., Stevels. Review 2008, Danish Ministry of the Environment of Directive 2002/96 on Waste Electrical Available from https://www2.mst.dk/udgiv/ and ElectronicEquipment (WEEE) (No. publications/2008/978-87-7052-733-0/pdf/978- 07010401/2006/442493/ETU/G4). United 87-7052-734-7.pdf [Accessed 10.07.2019] Nations University, Bonn, Germany. Available (11) Babbitt, C. W., Williams, E., & Kahhat, R. from Urbanization ASIA. 2012 Sept;3(2): p. 385-96. (20) Ovchinnikov Anton. Revenue and Cost (19) Mella Yla, Keiski & Pongracz. Electronic Waste Management for Remanufactured Products. Recovery in Finland: Consumers’ Perception Journal of Production and Operations Towards Recycling and Re-Use of Mobile Management. 2011 Nov;20(6): p. 824 – 84. Phones: Waste Management. 2015 Nov;45: p. (21) UNEP. United Nations environment programmed. 374-84. Life cycle management, a business guide to sustainability. 2011. Available from www.unep. fr/shared/docs/publications/LCM_guide.pdf? [Accessed 10.07.2019]. DOI Number: 10.37506/ijphrd.v12i1.13903 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 545 Polycyclic Aromatic Hydrocarbons in Fresh and Smoked Clupea heregus and Hake Fish Consumed in Ekiti State, Nigeria and their Health Implications Adeolu J. Adesina1, Samuel S. Asaolu2, Samuel O. Adefemi3, Abdul A. Olaleye4, Abiodun F. Akinsola5, Kolade A. Idowu6 1Senior Lecturer, 2Professor, 3Professor, 4Lecturer,Chemistry Department, Federal University Dutse, Jigawa State Nigeria, 5Senior Lecturer, 6Post graduate Student, Department of Chemistry, Ekiti State University, P.M.B 5363, Ado- Ekiti, Nigeria Abstract Levels of polycyclic aromatic hydrocarbons (PAHs) in fresh and smoked Clupea herengus (shawa) and Hake (panla) fish commonly consumed in Ekiti State, Nigeria were investigated using gas chromatographic method. Effect of smoking on the PAHs level was also considered. The PAHs concentration ranged from 0.0001 µg/kg Acenapthene and Indeo (1,2,3-cd) pyrene to 0.240 µg/kg (Benzo (a) pyrene) for fresh unsmoked Clupea herengus (SF), 0.0001µg/kg Acenapthene and Anthracene to 0.638 µg/kg Benzo (b) fluoranthene for smoked C. herengus (SF), 0.0001 µg/kg Acenapthene, Anthracene, Fluoranthene and Benzo(ghi) perylene and Indeno(1,2,3-cd)pyrene to 0.171 µg/kg (Benzo (a) pyrene) for fresh Hake (panla) fish (PF) and 0.0001 µg/kg Indeno(1,2,3-cd)pyrene to 0.966 µg/kg pyrene for smoked Hake (panla) fish (PS) samples. Results also revealed TPAHs levels in the smoked fish were 62.3-62.5% times higher than the fresh. Values of PAHs levels in the fish samples were below EU-regulatory limits (30µg/kg) for PAHs. Hazard index and lifetime excess carcinogenic risk of the samples revealed no potential cancer and mutagenic risks. Keywords: Clupea herengus and Hake, hazard index, polycyclic aromatic hydrocarbons, gas chromatograph Introduction frying). PAHs are formed by incomplete combustion process which occurs whenever wood, coal or oil are Polycyclic aromatic hydrocarbon (PAHs) are wide burnt, the absorption and deposition of particulates spread organic pollutant in the environment1. They are during food processing such as smoking, grilling, boiling known to be potent carcinogens2. They are also known and toasting, the pyrolysis of fats and the incomplete for their mutagenic effects and bio-accumulate in combustion of charcoal4. animal and human tissues1. Ishizaki et al.3 reported that PAHs are usually present in the various environments In foods of animal origin, it was proposed that or supernatant i.e in water, air, soil and traces of them the lipophilic character of PAHs is responsible for the discovered in some food products. Many exposure accumulation in the fat of animal which eat contaminated routes have been reported for PAHs, among which is a plants 5. They have been reported to occur as contaminants thermal treatment that occurs during processing of food in different food categories and beverages including (drying and smoking) and cooking (roasting, baking and water fresh and smoked fishes fruit, cereals and oil6-7. Non processed fish contain low PAHs concentration even when it comes from contaminated water because fishes Corresponding Author: rapidly metabolize PAHs resulting in low steady state Adeolu J. Adesina level in the tissue8. Health effects of PAHs have been E-mail: [email protected] reported to include: growth retardation, low birth weight, 546 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 small head circumference, low IQ, damaged DNA in making quality protein available to the poor people unborn children and disruption of endocrine systems in most developing countries of the world including such as estrogens, thyroid, and steroid8. According to Nigeria21. FDF22 noted that almost half of the total Devos9, PAHs have been included in several priority animal protein consumed in Nigeria is from fish and fish pollutant Lists of the Agency of Toxic substances and products and this makes it to occupy a unique position Disease Register (ATSDR), the International Agency for being the cheapest source of animal protein. In Nigeria, Research on Cancer (IARC), the European Community the most populous country in Africa, fish is an important (EC) and environmental protection agency (USEPA) and part of the household diet. Fish makes up around 40% of to this end, several studies have been done to determine the country’s protein intake, with fish consumption the levels of exposure of humans to PAHs. Farhadian et at 13.3 kg/person/per year.Total fish production al.10 have identified diets as the major source of human per year is close to 1 million metric tons (313,231 exposure to PAHs as it accounts for 88% to 98% of such metric tons from aquaculture and 759,828 metric tons contamination. Processing of food at high temperature from fisheries). The majority of this fish is consumed (grilling, roasting, frying and smoking) are major domestically, while around 10% is exported23. source producing PAHs. Gullen et al.11 have reported Among the marine fishes consumed various levels of individual PAHs in smoked fish and in Nigeria are Clupea heregus and Hake. meat samples (up to 200µg/kg) and about 130µg/kg in Clupea is genus of planktivorous bony fish belonging barbecued meat whereas in an uncooked food samples a to the family Clupeidae, commonly known as herrings. level range between 0.01 to 1µg/kg was reported. They are found in the shallow, temperate waters Smoking as one of the oldest food preservation of the North Pacific and the North Atlantic oceans, technologies have been used to achieve characteristics including the Baltic Sea. Three species of Clupea are taste, colour and aroma for food (especially fish and fish recognized. The main taxa, the Atlantic herring (Clupea products meat and meat products12. Smoking enhances harengus) and the Pacific herring (Clupea pallasii) may preservation due to the dehydrating bactericidal each be divided into subspecies. Herrings are forage and antioxidant properties of smoke such as phenol fish moving in vast schools, coming in spring to the derivatives, carbonyls furan derivatives, organic shores of Europe and America, where they form acids and their esters13. The actual levels of PAHs in important commercial fisheries. Adult herring are the smoked foods depend on several variables in the harvested for their meat and eggs, and they are often smoking process, including type of smoke generator, used as baitfish. The trade in herring is an important combustion, temperature and degree of smoking14. sector of many national economies. In Europe the fish Considerable amount of PAHs can be produced by has been called the “silver of the sea”, and its trade has incomplete combustion of wood during smoking and been so significant to many countries that it has been these can penetrate through the surface of products7, 15- regarded as the most commercially important fishery 17. in history24. Environmental Defense has suggested that the Atlantic herring (Clupea harengus) fishery is one Fish is known worldwide as a very important of the more environmentally responsible fisheries25. component of human diet because of its high nutritive Hake is in the same taxonomic order (Gadiformes) value and significance in improving human health18. It as cod and haddock. It is a medium-to-large fish contributes significantly to the survival and well being averaging from 1 to 8 pounds (0.45 to 3.63 kg) in of a large number of the people around the world. Fish weight, with specimens as large as 60 pounds (27 kg)26 is an important source of essential nutrients which The fish can grow up to 1 metre (3 ft 3 in) in length with includes; protein, lipids, vitamins and minerals19. Fish a lifespan of as long as 14 years. Hake may be found in is known to be efficient converter of food for human the Atlantic Ocean and Pacific Ocean in waters from 200 consumption and saving children from kwashiorkor due to 350 metres (656 to 1,148 ft) deep. The highest demand to low protein intake and unbalanced diet and there is for hake has been in Europe. Hake has been primarily little or no religious restriction on its consumption20. divided into three principal levels—fresh, frozen, and Fish is relatively cheaper and readily available, therefore frozen fillet. Fresh hake is mainly supplied by European Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 547 production and imports. Frozen hake and frozen hake and activity/grade 1). 10 ml of the treated alumina was fillet are effectively supplied by imports and European packed into the column and cleaned properly with processing companies. Hake is sold as frozen, fillets or n-hexane. The extract was poured onto the alumina and steaks, fresh, smoked, or salted 26. was allowed to run with the aid of the n-hexane to remove the aliphatic profiles into the pre-cleaned 20 ml capacity Considering the potential risk posed by PAHs to glass container. The mixture was concentrated to 1.0 ml public health, the study seeks to determine the effects of by stream of nitrogen gas before the gas chromatography smoking process on PAHs content in fresh and smoked analysis7. samples of two major fishes Clupea harengus (Shawa fish) and Hake fish (Panla) consumed in south western Gas chromatographic condition part of Nigeria. The gas chromatography conditions for the analysis Materials and Methods of PAHs were as follows: GC model: HP6890 powered with HP ChemStation Rev. A 09.01[1206]; the carrier Sample collection and preparation gas flow rate was 2.0 ml/min; injector temperature: Split Fresh fish and commercially smoked fish of two injection: 20:1; carrier gas: nitrogen; inlet temperature: o different species commonly consumed in Nigeria, 250 C; column type: HP-1 ; column dimension: (30 namely Clupea herengus (Shawa fish) and Hake (Panla m x 0.25 µm x 0.25 mm; oven programme: initial o o fish) were purchased from ten different local fish vendors temperature at 60 C for 5 minutes, first ramping 15 C/ o in Ado-Ekiti major markets. Fresh and commercially min for 14 min (180 C); maintained for 3 min; second o o smoked fishes from these vendors were pooled together ramping at 10 C/min for 5 min (300 C); maintained for to obtain representative samples for each of two types of 4 min; detector: flame ionization detector (FID); detector o fish species. The trunk (muscle) part used for this analysis temperature: 320 C; hydrogen pressure: 28 psi; nitrogen was carefully separated, composited, homogenized, column air: 30 psi; compressed air: 32 psi. The total run 7 packed in amber bottles and kept in the refrigerator prior time was 31 minutes . to analysis. Estimation of Benzo(a)pyrene equivalent Reagents used In determining the carcinogenic risk from exposure The reagents used were of spectra purity. They to PAHs in fish, the USEPA guideline, as described by 29 included GC grade dichloromethane (DCM), n-hexane Cheung et al. was employed. In this method, benzo(a) and alumina. pyrene is used as a marker for the occurrence and effect of carcinogenic PAHs in food. The overall carcinogenic Extraction and clean-up procedure of the health risk from the measured PAHs was estimated samples for PAHs analysis based on toxic equivalence factors (TEFs) derived from the cancer potencies sof individual PAH compounds The extraction method for the analysis of polycyclic relative to the cancer potency of benzo(a) pyrene30. The aromatic profiles in the samples was by employing benzo(a)pyrene equivalent concentrations TEQ is the modified methods of ASTM27 and ASTM28. Fifty Bap the sum of product of each individual PAH and its TEF gramme of each sample was carefully taken and 31. The mutagenicity of individual PAH relative to BaP emptied into a 27 ml capacity McCartney bottle of had also been computed using the mutagenic equivalent borosilicate material and 10 ml of the ratio 3:1 n-hexane: factor (MEF) proposed by Durant et al.32-33. The sum of dichloromethane was added. The bottle and its content the concentration of each individual PAH multiplied by were placed in the sonicator to extract the hydrocarbon the corresponding MEF gives the mutagenic equivalent for about 2 hours. The organic layer was filtered into 250 (MEQ) (Table 5). ml capacity borosilicate beaker7. ………..i The concentrated oil was separated into the aliphatic profile and polyaromatic hydrocarbons profiles by ……….ii packing the glass column with activated alumina (neutral 548 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Where Ci is the measured individual PAH 21 package. concentration for the (ith) compound with the assigned Result and Discussion TEFi or MEFi. The PAHs concentration µg /kg in non-smoked Determination of dietary exposure to PAHs fresh clupea herengus (Shawa) and Hake (Panla) Human dietary exposure doses express as (mg kg-1 samples were presented in the Table 1. The PAHs BW day-1) occurring over a lifetime were determined. levels were present in various concentrations ranging between 0.0001 and 0.996µg/kg in all the samples of fish analysed. PAH of significant concentrations in the samples were as follows: unsmoked fresh clupea Where, IR is the ingestion or intake rate of herengus pyrene (0.124), Benzo(b)fluoranthene (0.190), carcinogenic (mutagenic) PAHs based on average fish Benzo(a)pyrene (0.240) and Dibenzo (a,h) anthracene consumption rate set at 68.5 g day-1 per person from (0.155); smoked clupea herengus: phenanthrene the annual per capital fish consumption of 25 kg for (0.929), fluoranthene (0.306), chrysene (0.467), Nigeria34. CF is the conversion factor (0.001 mgkg-1) Benzo(b) fluoranthene (0.638). The total PAHs (∑16 and BW is the body weight which is set at 70kg. PAHs) were 1.05 and 2.80, ∑ non-carcinogenic PAHs (0.226 and 0.382) and ∑ carcinogenic PAHs were Non-cancer hazard, carcinogenic and mutagenic 0.752 and 1.39µg/kg respectively for unsmoked fresh risk calculations and smoked clupea herengus (shawa fish) samples. The risk associated with the dietary exposure to Generally, the following PAHs were enchanced by non-carcinogenic PAHs was evaluated using hazard smoking: naphthalene acenaphthylene, fluorene, quotient approach. Hazard quotient represents a ratio of and phenanthrene, fluoranthene, pyrene, benzo (a) the exposure dose for each PAH divided by reference anthracene chrysene, Benzo(b)fluoranthene and indeno dose (RfD). (1, 2, 3, cd) pyrene with the highest % enchancement in phenanthrene ( -0.9149). …………… iv In Hake fish (panla) samples the following PAHs were enchanced by smoking napthalene , acenaphthene Summation of individual hazard quotients results fluorine, anthracene, fluoranthene, pyrene, benzo(K) gives the hazard index was calculated using the reference fluoranthene and dibenzo (a,h)anthracene .however the doses for non-carcinogenic PAHs. PAHs wthh major concentration µg/kg in unsmoked ………………..v fesh hake fish (panla) and smoked samples were :pyrene (0.156 and 0.966), bonzo(b) fluoranthene (0.156and The calculated TEQBap and MEQBap for the seven 0.179) and dibenzo (a,h) anthracene (0.156 and 0.162) USEPA classified carcinogens (mutagens) were used to respectively. estimate carcinogenic and mutagenic risk involved in ingestion of fresh and smoked fish for a life time of 70 The level of individual PAHs in the two samples years35. The total risk due to exposure to mixtures of reported were in close agreement with what was reported carcinogenic (or mutagenic) PAHs is the product of the for cat and sole fish subjected to traditional and modern 6 dietary carcinogen exposure dose (mg kg-1 BW day-1) smoking methods , Arius heude loti and cynoglossus 2 and benzo (a) pyrene slope factor value are shown Table senegalensis samples smoked by traditional method . 5. The individual PAHs of lower molecular weight found to increase in smoked samples could be attributed to the lower average wood temperature used in the smoking Statistical Analysis process36. This is an indication that smoking process contributed to the general increase in the percentage Data obtained from the analysis were subjected to concentration of the PAHs. Of note is the concentration correlation analysis using IBM SPSS Statistics version of benz(a)pyrene which is usually used as biomarker in Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 549 monitoring carcinogenic PAHs6 had mean concentration From the result in Table 3, the TEQ for the much lower than the maximum tolerable limit of seven USEPA priority carcinogens were SF (1.16e- 5.0 and 20µg/kg in smoked fish established by the 3), SS (2.06e-3), PF (2.47e-4) and PS (1.23e-3). The 37 European Commission Regulation and Turkish Codex corresponding EQBap daily dose and carcinogenic risk Regulation38 respectively. Hence the result obtained for an adult involved in life time of 70 years ingestion in this work therefore indicated that the smoked fish of the unsmoked fresh and smoked fish samples were samples may not contribute to cancer and cancer –related calculated to be 1.14e-6, 1.99e-6, 2.42e-7 and 1.20e-6 health problems among the consumers because benzo(a) mg /kg /day respectively for a risk of 2.43e-3,5.14e-1, pyrene is commonly known for its carcinogenity and 6.24e-2 and 3.10e-3(hazard index) smoking 1 out of mutagenicity, although further studies may be needed to 1000000 adults is likely to suffer from cancer in their established this nevertheless, consumers and fish vendor lifetime .this implied that the consumption of Clupea may need to be careful of repeated smoking as a way of herengus (Shawa) and Hake (Panla) prepared by preserving these fishes to avoid buildup of PAHs levels traditional smoking pose no risk because they were thereby increasing the chances of causing health problem lower than the USEPA39-40 carcinogenic unit risk 1x10- 5 (carcinogenesis threshold). The source characterization of PAHs in the unsmoked fresh and smoked samples of Clupea herengus Also the Table 3, the risk assessment based on and Hake (panla) were depicted in Table 2. Indicator of carcinogenic equivalent, average daily dose and the risk pollution and mechanism of PAHs distribution (source) associated with the fish samples. Based on the calculated are usually obtained from PAHs ratios of selected life time excess carcinogenic (LECR) implied the compounds. Adeyeye et al.7 compiled standard values consuming the samples would not pose any health risk ratios on PAHs sources as shown in Table 3. The ratios to human. Provided a repeated smoking is not done for of [Ant/(Ant+phe)] in this study was between 0.000108 preservation. and 0.569 an indicator of predominance of petrogenic The mutagenic equivalent for the PAHs calculated source for PAHs (ratios <0.1) except for Hake (Panla) were: SF (3.04e-1), SS (1.35e-1) PF (2.66e-1) and PS 0.569>0.1, showing that wood was the major source of (1.58e-1) for unsmoked fresh and smoked fish samples contribution of PAHs in the samples. The [flu|(flu+chr)] prepared by traditional smoking method (Table 3). The ratio also ranged from 0.000633 to 0.805 which indicated corresponding EQ daily doses were also calculated both wood and petroleum as a source for the PAHs in Bap to be 2.97e-4 (SF), 1.33e-4(SS), 2.60e-4(PF) and 1.54e- the smoked fish samples [BaA/(BaA+Chr)] (Bap/BghiP) 4 (PS), (Tables 3 and 5) based on the mutagenic risks and [Icdp/(Icdp+Bghip)] ratios further confirmed that and LECR involved in ingestion of these smoked fish the PAHs levels were generally from both wood and samples, people are likely to suffer from non-cancer and petroleum sources. other cancer related disease in their life time if repeated Risk assessment based on non-carcinogenic smoking method is adopted for preservation. Generally, equivalent, average daily dose and harzard index of the relatively lower ∑MEQBap and mutagenic risk values fish samples were shown in Table 3. The carcinogenic below the acceptable USEPA35,39 unit risk of 10-2 and -4 toxicity (TEQBaP) and mutagenic toxicity (MEQBap) 10 respectively were recorded for Clupea herengus relative to B(a)p were calculated for the carcinogenic and Hake fish (Panla) prepared by traditional smoking and mutagenic risk associated with ingestion of the method. smoked fish (Tables 1 and 8). Essumang et al. (2013) Table 4 presents the statistical analysis of the results reported that while TEQBap is directly associated with based two-tailed correlation. The results were significant carcinogenicity, MEQBap(mutagenic activity) may at p . not be directly associated with cancer and may have =0.05 implication for other non-cancerous adverse effect Conclusion like pulmonary disease, birth defect, impotency, low intelligent quotient. This research has shown that smoked Clupea herengus and Hake were fit for human consumption. 550 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 The levels of PAHs, Hazard index and cancer risks samples and this may result in health-related ailments obtained in the present report were within the safe levels with time if the processing method and consumption is specified by EU and USEPA regulations, however, not regulated. This therefore requires proper education smoked samples from commercial fish vendors showed of fish monger/vendor about safe smoking practices that elevated level of PAHs compared to the unsmoked fresh would not enhance the level of toxic substances which may lead to health problems. Table 1. Concentration (µg/kg) of PAHs in the fresh and smoked fish muscle samples PAHs SF SS Mean CV% Diff (%) PF PS Mean CV% Diff (%) Naphthalene+ (Nap) 0.0081 0.0439 0.026 97.5 0.0352(443) 0.0082 0.040 0.0241 93.0 -0.032(384) Acenaphthylene+ 0.0173 0.0336 0.0255 45.3 -0.016(94.2) 0.0153 0.0105 0.0129 26.3 0.0048(31.4) (Acy) Acenapthene+ (Ace) 0.0001 0.0001 0.0001 0.0 0.00(0.00) 0.0001 0.0323 0.0162 141 -0.032(32200) Fluorene+ (Flu) 0.0184 0.0221 0.0203 12.9 -0.004(20.1) 0.0145 0.0309 0.0227 51.1 -0.0164(113) Phenanthrene+ (Phen) 0.0142 0.929 0.472 137 -0.9148(6442) 0.0397 0.0088 0.0243 89.9 0.0309(77.7) Anthracene+ (Ant) 0.0094 0.0001 0.0047 138 0.0093(98.9) 0.0001 0.0116 0.0059 139 -0.0115(11500) Fluoranthene* (Flt) 0.0155 0.306 0.161 128 -0.2905(1874) 0.0001 0.0283 0.0142 140 -0.0282(28200) Pyrene* (Pyr) 0.124 0.0741 0.0991 35.6 0.0499(40.2) 0.158 0.966 0.562 102 -0.808(511) Benz(a)anthracene** 0.0221 0.0614 0.0418 66.6 -0.0393(178) 0.0173 0.0503 0.0338 69.0 -0.033(191) (B(a)A Chrysene** (Cry) 0.0572 0.467 0.262 111 -0.4098(716) 0.0322 0.221 0.127 105 -0.189(586) Benzo(b) 0.190r 0.638 0.414 76.5 -0.4480(236) 0.156 0.179 0.168 9.71 -0.023(14.7) fluoranthene** (B(a)F) Benzo(k) 0.0877 0.088 0.0879 0.241 -0.0003(0.342) 0.0001 0.0964 0.0483 141 -0.096(96300) fluoranthene** (B(k)F) Benzo(a)pyrene** 0.240 0.0885 0.164 65.2 0.1515(63.1) 0.171 0.0964 0.134 39.5 0.075(43.6) (B(a)P) Dibenz(a,h) anthracene**(DB 0.155 0.0238 0.0894 104 0.1312(84.6) 0.115 0.162 0.139 24.0 -0.047(40.9) (ah)A) Indeno(1,2,3-cd) 0.0001 0.0210 0.0106 140 -0.021(21000) 0.0001 0.0001 0.0001 0.00 0.00(0.00) pyrene** (IP) Benzo(g,h,i)perylene* 0.0868 0.0016 0.0442 136 0.0852(98.2) 0.0001 0.0001 0.0001 0.00 0.00(0.00) (B(ghi)P) ∑ 16 PAHs 1.05 2.80 1.93 64.3 -1.75(167) 0.727 1.93 1.33 64.0 -1.20(165) ∑LMW –PAHs 0.0673 1.03 0.548 124 -0.9613(1427) 0.0777 0.134 0.106 37.6 -0.056(72.4) ∑HMW- PAHs 0.978 1.77 1.37 40.7 -0.7911(80.9) 0.650 1.80 1.22 66.4 -1.15(177) ∑nc –PAHs 0.226 0.382 0.304 36.1 -0.1554(68.7) 0.158 0.994 0.576 103 -0.84(529) ∑7c –PAHs 0.752 1.39 1.07 42.0 -0.6357(84.5) 0.492 0.805 0.648 34.2 -0.314(63.8) PF= frsh Hake, PS= smoked Hake, SS= smoked Clupea heregus, SF= fresh Clupea heregus, SD= standard deviation; CV=coefficient of variation; +indicates PAHs classified as low molecular weight PAHs; *= high molecular weight and non carcinogenic PAHs; ** = high molecular weight and carcinogenic PAHs; ∑7c-PAHs= sum of seven carcinogenic PAHs, ∑nc-PAHs= sum of non carcinogenic PAHs; ∑LMW-PAHs= sum of low molecular weight PAHs; ∑HMW-PAHs= sum of high molecular weight PAHs Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 551 Table 2. Source characterization of PAHs in the muscle of the fish samples PAH ratios SF SS PF PS Standard Value ratios 7 Remark LMW PAHs/ >1 Petrogenic 0.069 0.581 0.120 0.0745 HMW PAHs <1 Pyrogenic <0.1 Petrogenic [Ant /(Ant + Phe)] 0.398 1.08e-4 2.50e-3 0.569 >0.1 Wood <0.4 Petrogenic [Flu/(Flu + Cry)] 0.111 0.805 6.33e-4 0.0284 >0.5 Wood <0.2 Petrogenic [B(a)A /(B(a)A + Cry)] 0.279 0.112 0.349 0.187 1.2 – 50 Wood >0.6 Petrogenic [B(a)P/B(ghi)P] 2.76 55.3 1710 964 1.2 – 5.0 wood <0.5 Petrogenic [IP/(IP + B(ghi)P] 0.0012 0.929 0.5 0.5 >0.5 Wood Ant = anthracene, Phe = phenanthrene, Fla = Fluoranthene, Py = Pyrene, BaA= benzo(a)anthracene, Cry = chryene, BaP= benzo(a)pyrene, BghiP= benzo(g,h,i)perylene, IcdP= Indo(1,2,3-cd)pyrene Table 3. Calculated risk assessment based on non-carcinogenic, carcinogenic, mutagenic equivalent, average daily dose and hazard index for the muscle of fish samples PAHs Non-carcinogenic Equivalent7 PAHs Carcinogenic equivalent7 Mutagenic equivalent7 SF SS PF PS SF SS PF PS SF SS PF PS Nap 8.10e-6 4.39 e-6 8.20 e-6 3.99 e-5 B(a)A 2.21 e-3 6.14 e-3 1.73 e-3 5.03 e-3 1.81e-3 5.03 e-3 1.42 e-3 4.12 e-3 Acy 1.73 e-5 3.36 e-5 1.53 e-5 1.05 e-5 B(b)F 1.92 e-2 6.38 e-2 1.56 e-2 1.79 e-2 3.23 e-3 1.08 e-2 2.65 e-3 3.04 e-3 Ace 1.00 e-7 1.00 e-7 1.00 e-7 3.23 e-5 B(k)F 8.77 e-4 8.80 e-3 1.00 e-6 9.64 e-4 9.65 e-3 9.68 e-3 1.10 e-5 1.10e-5 Flu 1.84 e-5 2.21 e-5 1.45 e-5 3.09 e-5 B(a)P 0.240 8.85 e-2 0.171 0.096 2.40 e-1 0.0885 0.171 0.0964 Phen 1.42 e-5 9.29 e-4 3.97 e-5 8.80 e-7 DB(a,h)A 1.55 e-2 2.38 e-3 0.0115 1.62 e-2 4.81 e-2 7.38 e-3 3.57 e-2 5.02 e-2 Ant 9.40 e-5 1.00 e-5 1.00 e-6 1.16 e-4 Cry 5.72 e-3 4.67 e-2 3.22 e-5 2.21 e-1 9.72 e-4 7.95 e-3 5.47 e-2 3.76 e-3 Flt 1.55 e-5 3.06 e-4 1.00 e-7 2.83 e-5 IP 1.00 e-4 1.60 e-3 1.00e-4 1.00e-4 2.90 e-5 6.09 e-3 2.90 e-5 2.95 e-5 ∑BaP Pyr 1.24 e-4 7.41 e-4 1.58 e-4 9.66 e-4 2.84 e-1 2.18 e-1 2.00 e-1 3.58 e-1 3.04 e-1 1.35 e-1 2.66 e-1 1.58 e-1 TEQ B(ghi)P 8.68 e-4 1.60 e-5 1.00 e-5 1.00 e-5 ------ ∑BaP 1.16 e-3 2.06 e-3 2.47 e-4 1.23 e-3 LECR 0.043 0.033 0.0304 0.0543 0.0461 0.0206 0.0403 0.0239 TEQ BaP TEQ daily 1.14 e-6 1.99 e-6 2.42 e-7 1.20 e-6 - 2.77 e-4 2.13 e-4 1.96 e-4 3.50 e-4 2.97 e-4 1.33 e-4 2.60 e-4 1.54 e-4 dose mg kg-1 day-1 HI 2.43 e-3 5.14 e-1 6.25 e-2 3.10 e-3 ------ HI=Hazard index 552 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 Table 4. Statistical analysis of the results from Table 1 Nap Acy Ace Fl Phe Ant Flu Py BaA Chr BbF BkF BaP DahA IcdP BghiP Nap 1 Acy .406 1 Ace .509 -.577 1 Flt .783 -.189 .897 1 Phe .627 .962* -.351 .036 1 Ant .040 -.641 .692 .625 -.595 1 Flu .690 .941 -.270 .133 .994** -.507 1 Py .444 -.638 .997** .858 -.418 .696 -.342 1 BaA .987* .528 .389 .718 .719 -.004 .780 .317 1 Cry .901 .762 .089 .469 .899 -.266 .935 .013 .951* 1 B(b)F .650 .958* -.321 .085 .996** -.526 .998** -.392 .747 .915 1 B(k)F .603 .196 .416 .725 .264 .614 .361 .355 .653 .532 .346 1 B(a)P -.919 -.314 -.493 -.646 -.562 .187 -.596 -.446 -.866 -.795 -.551 -.248 1 DB(ah)A -.454 -.940 .504 .197 -.955* .807 -.918 .555 -.536 -.762 -.926 .034 .493 1 IP .642 .959* -.333 .059 1.000** -.571 .997** -.402 .734 .908 .998** .292 -.567 -.945 1 B(ghi)P -.569 -.109 -.341 -.293 -.328 .443 -.313 -.333 -.477 -.444 -.274 .295 .848 .417 -.318 1 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 553 Table 5. Proposed benzo(a)pyrene equivalent factors for carcinogenic (TEF)41, mutagenic toxicity (MEF)32- 33 , reference dose (RFD) and cancer slope factor (CSF)42 PAHs TEF MEF RfD (mg kg-1 day-1) CSF (mg kg-1 day-1) Nap 0.001 2.00 × 10-2 Acy 0.001 2.00 × 10-2 Ace 0.001 6.00 × 10-2 Flu 0.001 4.00 × 10-2 Phen 0.001 - Ant 0.01 3.00 × 10-2 Flt 0.001 4.00 × 10-2 Pyr 0.001 3.00 × 10-2 B(a)A 0.1 0.082 7.30 × 10-1 Cry 0.001 0.017 7.30 × 10-3 B(b)F 0.1 0.25 7.30 × 10-1 B(k)F 0.01 0.11 7.30 × 10-2 B(a)P 1 1 7.3 IP 1 0.29 7.30 × 10-1 DB(a,h)A 0.1 0.31 7.3 B(g,h,i)P 0.01 4.00 × 10-2 Source: Adeyeye et al7 (PAHs) in some locally consumed fishes in Nigeria. African Journal of Food Science, 2011; 5(7): 384- Conflict of Interest: Nil 391. Source of Funding: Self-funding 3. Ishizaki A, Saitoa K, Haiokab N, Narimatsub S, Kataokaa H. 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